basic operative

[Benchwmer]

Robert,
Nice results and photos.
Can you and all posters give us more information, on techniques used?
What laser was used, settings, tips used, duration for prepation? LA?
Any additional devices used for caries removal?
How restored, materials, etch? DBAs.
Patient information, adult? child? pre-existing conditions, any complications, post-op disposition.
I read posts to learn from how others approach and treat their cases.
Would appreciate the info to how the cases are treated.
Thanks.
Jeff

[jetsfan]

Jeff,
Good idea.
I was using the Wayerlase on this 25y/o male. Came to me because he was afraid of dentists and his girlfriend convinced her I was safe. We do use Nitrous with him routinely.
For Anesthesia I use Dr. Chen’s turtle technique;1.25W 15/15, then 2W 30/30 and 4W60/60. I then drop down to 3W 60/30 to outline the prep and go throgh enamel. At that setting I also drop down the inerprox box trying not to break the marginal ridge completely but rather keep a thin layer adjacent to the proximal tooth. Once into dentin I drop to 2-2.5 W. I will use a spoon to remove the interprox emanel shell , and remove decay. I sometimes will use slow spped round bur(I dont remember if it was used here). I will confirm decay removal with caries detect. then a final hit with the laser at 1.5W to remove smear layer. I bevel Cavo surface with a football shaped diamond.
Garrison mgold matrix, ring and plastic wedges were employed. I use Graeme techinque for restoring the tooth( fuji 9 build up. after conditioning dentin and etching cavo surface enamel.bonding agent, flowable and the “compressible ” composite.
Great patient, wish I had the video camera running.

Robert.

[dkimmel]

Robert I lost track of this thread.
When we changed our name to the Fl Center for Laser Dentistry alot of homework was done. We talked about it to our patients at each visit. We announced it in our newsletter. We answered our phone for at least 6 mo . Dr Kimmels Fl Center for LAser Dentistry. Then dropped the Dr, Kimmel. All of our marketing also used both names. Finally we changed our sign.
It worked!
DAvid

[N8RV]

Kelly, well said.

I’ve struggled some as I’ve negotiated this learning curve, and would agree with your assessment 100%. It ruffles my feathers some to see lasers promoted as “painless”, because “pain” is different for everyone.

I’ve come to accept that it makes no real sense that I can do a pretty deep restoration with no anesthetic and the patient only comments once about any discomfort — usually with the round bur just as I’m going after that last soft spot! It’s truly amazing. However, I can do a similar, if not significantly smaller, restoration on someone who claims to feel everything and is pretty jumpy, making my life miserable. I can usually finish the restoration without anesthetic, but when I ask the patient after we’re done, the response is usually, “It was OK, but next time, I think I’ll have you get me numb.” Who benefits from that?

So, I think I’ll take your tack and start probing the patients more about what they’d prefer. Like everybody else, I’d love to provide truly painless, noiseless, vibrationless dentistry to all my patients, but MY lasers won’t do that.

I can’t help but feel that the practitioners who boast a 90% rate of success with the laser with no anesthetic are just a bit more thick-skinned than I when it comes to inflicting some discomfort. I guess I’d rather make the patient comfortable at the earliest opportunity rather than discourage the patient with this new technology, just for the sake of having a high percentage to brag about.

Thanks for a good post, Kelly, and the encouragement. I need to focus more on my patients’ expectations and wants than on my own.

— Don

[dkimmel]

Don, Great post and you bring up some great points. The perception of Pain is so different form one patient to another and even on the same patient at different times. It is if there are factors that are not within our control that modulate the patients response to a stimulus. That is some days it is cranked up and if you just look at them it hurts or cranked down and nothing bothers them. These could be hormonal factors, physiological factors , having a chronic pain condition or just not getting a good nights sleep.

This may sound wired but another thing to consider is how the patients reads your body language, One of the things I learned while helping Stu is reading dentist body language. You could tell real fast who was going to have an easy time and who needed more hands on just by watching their nonverbal communication. Patients can tell how confident you are in what you are doing by reading your body language. If you have that air of confidence in what you are doing it helps calm the patient and thus turns that modulation dial down. Act like your not sure of yourself and they will be waiting for it to hurt.

Patient expectations vs the dentist. This is a big one. It all goes back to knowing your patient and what they want vs. what you want. If they don¡¦t mind a shot and are doc ¡§I just don¡¦t want to feel anything.¡¨ I¡¦ll dig around in the drawer and see if I can find a syringe and then numb them up. ƒº If they hate the shot, I¡¦ll do what I can to make them comfortable. Its their nickel so I¡¦ll do what makes them happy. If they don¡¦t care I do what makes me happy. You just have to ask the patient and they will tell you. The act of just asking tells them you care and this alone helps turn this dial down.

Patient population. I was talking with a good friend that started about the same time I did using the lasers. He was real frustrated with his pain free results. This guy is good and it just did not make since to me as I am one of those high 90¡¦s guys. Then we compared patients. His where all younger and high % of females, redhead Irish types. Mine are older and form the mid west. I do have a high a % of females but they are post menopause. I have to believe this is a huge factor in my success .

The laser settings. This is an obvious one. Everyone uses a bit different settings and each laser is different . What is truly 2 W on my laser may not be 2 W on your laser at the tip. I cut a bunch at 10HZ an others at 30HZ. I also think telling the patient that they will feel air and water is important. Letting them know that if they think they are feeling something other then this to let you know. That you can make changes in your setting on the laser. That each patient is different and each tooth is different. I also like Marks Colona technique for numbing the tooth. Not just because I find it more predictable but also it gives the patient an ideal of what they are going to feel with the air and water. You are using the laser on them for a full 90 sec with higher W ( POP) and the most air and water. If you watch the patient during this 90 sec , you will find them very tense at first and during the last 30 sec they start to relax. This is a new experience for most of them. They are waiting for it to hurt. That 90 sec of air, water and noise gives them the time to see that this is OK and what to expect. On the other hand you are going to find out real fast if this is not going to work for this patient. If they are all over the chair during this 90 sec , then numb them up.

Reality . Ever had that patient you have tried to get numb and they still feel it on the distal lingual? Then you give them another shot and they still feel it. Then you give them a block and they still feel it. Then the ligajet and they still feel it? The laser is no different, you are still going to get that one patient that has that one spot.

The tooth: If you look at an X-ray on my patients often you can not see the pulp chambers. I would expect my results to be more predictable then someone who¡¦s patients are younger with larger pulp chambers. I also look for a occlusal trauma. If they have a nonworking side interference with a nice wear pattern, I¡¦ll numb them. They often are tough to get numb.

Caries. This maybe me but I have found that fresh carious lesions can often be the toughest to treat. The old leathery type lesions are the easiest.. Size is not important but more how active the caries is and how close this active lesion is to the pulp. This maybe be just a matter of the condition of the pulp at that time. I am think the older the lesion the more repairative dentin is in place an the less permeability there is. Where in a active newer lesion the permeability to the pulp is greater and the more acute the inflammatory process is in the pulp. Cranking that modulation dial way up.

Thick skin vs thin skin. This could be true but not always. Just part of the learning curve.

Hope this helps.

DAvid

[2thlaser]

David,
I couldn’t agree with you more. What a great thought out post.

“I can’t help but feel that the practitioners who boast a 90% rate of success with the laser with no anesthetic are just a bit more thick-skinned than I when it comes to inflicting some discomfort.  I guess I’d rather make the patient comfortable at the earliest opportunity rather than discourage the patient with this new technology, just for the sake of having a high percentage to brag about. “

The first thing Don, I would want to ask you is, do you understand the physics, even a bit? I can’t remember if you use the Waterlase or the DeLIght, so either way, the physics, how the tips ulitlize, and deliver energy, is so very important to understand, so that you can HAVE the higher success rates with laser anesthesia. Once you understand that, delivering the proper energy becomes second nature.

As David has said, each patient, and each tooth on each patient is different and can react different. I also need to add that using proper magnification is of UTMOST importance in using the laser. If you can SEE the tip, and the tissue interaction, you can have GREAT success with the laser on hard and soft tissue. I usally find, almost every class I teach, once the “student” has a chance to really SEE what the laser can do, they realize why they have had problems. This is also true once they get back to the office, and after ordering a pair, or just using the loupes they had put on the shelf, as they usually email me with thier success.

Usually, they find they have been holding the tip too close to their intended ablation surface, and holding the tip too close, sometimes at ANY power setting, will cause sensitivity. Once you can see the distance, focussed, or non-focussed the tip is from your intended target, it makes all the difference in the world. Thanks Glenn for pushing me into higher mags….scope is definitely next!

Just some thoughts to continue Davids…..I wish you much success and if you have any questions, just drop me an email.
Would love to see you successful in your laser endeavors!!

Sincerely,
Mark

(Edited by 2thlaser at 4:14 am on Nov. 9, 2004)

[Graeme Milicich]

Yup
Seeing is everything
Imagine if this was your total field of view!!!
This is a single frame captured off a video clip so it is not high definition, but you can see the distribution of energy across the footprint of a defocused C6 tip.  
The energy density is higher towards the periphery of the footprint, causing minor charring of the dentin.

The point I am trying to emphasise along with Mark, is success with any laser comes from seeing what you are doing.  You are watching the interaction of the laser energy with the target, aiming to get a certain effect, depending on what you are trying to do.

Like everyone else, I don’t get hung up on “No LA”.  I play it how I see it.  Nervous patients get LA, period, if I have any doubt about them sensing anything.  It is all perception, as has been well described on this string, but I refuse to get into the semantic game with the patient of calling what they are feeling anything other that what the choose to dscribe it as.

If they use the pain word, or ouch, or flinch, they get offered LA.  There is so much positive in using the laser that LA (or the lack of) is not even part of my discussion with patients

Cheers

(Edited by Graeme Milicich at 4:22 pm on Nov. 9, 2004)

[Glenn on the road]

Thanks Mark and Graeme….I can tell you that when I started using high magnification I was known as the scope guy. It was weird but now there is some authenticity to using microscopes and especially for lasers where such a huge part of the equation is the ability to see the interaction of the laser tip with the tissue BECAUSE YOU CANT FEEL IT.

We depend on tactile feel for so much of what we do in our profession but with lasers we need to have improved visual acuity of the operating field to be successful.

Many many times now the teachers who are training laser users discover that one of the major problems for why people struggle with lasers is that they arent using magnification at all.

Keep this fact in mind….

2X loupes provides 4X the visual information of the naked eye (length X width of the visual field is the are)

3X loupes are 9X what the naked eye can see or 2.5 X what you can see information wise compared to the 2X loupes.

10X loupes are 100X the naked eye (10 X 10) and they are 25 X more information than 2X loupes.

I know I harp on it but honestly, when I teach at people watch the interaction of the laser with the tooth at 10X power they suddenly understand how it is that I can figure out what motions cut the tooth best (circular and slow with small plunging motions ) and its not because of experience or guessing, its simply from seeing what works best.

I want to thank Mark for his kind words, for alot of the time I have been standing in a forest of trees , where no one can see or hear me……

The loggers have been thinning the old growth out and suddenly my voice can just about be heard.

heck if they cut all the trees down , one of these days alot of people might see me,

WITHOUT A SCOPE AT THAT.

Glenn

[whitertth]

Not many of u know this, but I have bit the bullet and two months ago started using my new Seiller Microsocope….All I can say Is Holy ****…U dont know what u r missing when your eyes cant see it…The mere fact of having the ability to actually see the power of the laser is incredible and almost essential to ideal treatment….It isnt easy to adapt to the laser in the beginning, but I am getting better and better everyday and it is sure an eye openning experience( no pun intended)

[dkimmel]

Glenn , we called you the wierd canadian scope guy! Not just the scope guy.
Ron K. congrates!
DAvid

[jetsfan]

Ron,
One of these days I have to drop by to see your operation. It sounds fantastic. Good Luck with the scope.

Robert

[kellyjblodgettdmd]

Congrats on your scope purchase, Ron. I purchased mine just over a year ago, and I don’t know how I practiced without it! Oh yeah, now I remember, I cut way too much tooth and I used way too much laser energy! I am constantly amazed at what I can do with just 1.0W of YSGG energy on teeth I thought I needed 2.5W or more when I couldn’t see as well or as big.
I think that these laser companies should wise up and purchase a scope comany or vise versa. What a combo!

I have to admit, I rely very little on the “We can do all your dentistry without any shots” campaign. I rely much more on listening to the patient. I’m sure you all do the same, but I am constantly surprised by phone calls from new users that think lasers are magic wands. Just because it’s a laser doesn’t mean that it won’t hurt. Granted, properly used it won’t hurt, but if the patient doesn’t want to feel ANYTHING, I usually reach for the Septocaine. But if they want to avoid shots completely, having a microscope sure makes keeping it comfortable much easier.

Great thread.

Kelly

[Graeme Milicich]

Kelly
I can’t believe where you are now, compared to a couple of years ago. I wish I had had the conviction in the past that you have demonstrated in encompasing new technology and making it work for you.

I was slow to start, I brought my scope in 1998, when they were not really considered of much use for general dentistry. It was the scope that changed the way I practiced dentistry.

Without the scope, I would never have seen the clinical detail of fissure caries when you open a fissure up with a fine air-abrasion tip, and would never have developed the knowledge base that allowed me to create the DIAGNOdent CD.

Poor Glen has been fighting the good fight trying to get the naysayers to believe you can do a better job when you use a scope. Anyone with a scope just nods in agreement, but until you have used one, you have no idea what you are missing.

Personally, I think everyone being trained on how to use a laser should have to do it under a microscope. Even if it is only cutting extracted teeth at 10-15X. WhenI trained dentists in air-abrasive microdentistry, it was alway under the scope, and they got to cut their first cavities using my scope. It as intersting to watch the first dentist struggle to do it right, and the others would be watching me help improve the technique by observing on a 21inch monitor. The fascinating thing was the last dentist always did the best job, almost without having to be guided because he had already seen the others making mistakes and correcting them. They were learning by proxy, and it was very successful

They all became very successful microdentists because they understood from the start what they were trying to achieve.

Success is in the detail, and good vision is a critical detail with any laser. A microscope lets you teach faster because the teacher can see exactly what the student is doing (as long has you have a video hooked up to the scope)

Cheers

[Glenn van As]

I am almost humbled by this thread…….I cant tell you how lonely it is sometimes when I talk about scopes. Lots of daggers later and alot of snickers, slowly I see that there is a grudging acceptance that scopes might have a role in general dentistry.

There is a greater acceptance out there on the need to see better for lasers and I am grateful for my friends here on LDF for that.

It is weird but I honestly think that alot of the naysaying stops when you show pictures and make points about energy settings that get people to stop and think…….hmmm…….how did he see that.

I will post a case or two of simple stuff soon.
Gotta sleep

Glenn

[2thlaser]

Glenn,
Your voice has NOT fallen on deaf ears. There are MANY out there in my travels, who have heard your gospel. Some can’t afford a scope, some don’t have physical room in their space for one, BUT, that being said, on the loupe side, you have helped me acheive great success with those forementioned “students” of minimally invasive laser dentistry.

I thank you for that. I am getting a scope soon, we are in the middle of a remodel, and will incorporate the scope into the financial process. It will either be a Global used by Ron Taturyan in Spokane, or a new one. Global keeps telling me they will contact me, in fact, since the World Congress in San Fran, they said they would call me within a week, and for almost 3 years, nothing. That is why I can honestly say I don’t have one yet. I don’t mean to come public with this, but I am very surprised that even though I live in a remote like area, that not even a phone call to plan a visit to see where, and what kind of scope we could purchase and install. We all talk about our lasers, and other equipment, and how the manufacturers are there for us, if I buy a scope, I want the same courtesy….service.

Anyhow, you are a great man to keep on about magnification, and I applaud you for your efforts, in fact, I JOIN YOU IN YOUR EFFORTS, and would be a proud colleague in that mission.

Graeme speaks about using the scope for training, which is how we did the workshop at WCMID….it was hugely successful, due to Ben Ong, and all the scope manufacturers. Global set theirs up with a large video screen and I prepped a tooth for a crown, and demontrated easy occlusals etc….what a great tool.

Anyhow, get some rest my friend. You are truly in a class all by yourself. Thanks for you, Graeme, Kelly, and all those who have helped spread the laser/magnification gospel. Let’s keep up the pace!!!

Sincerely,
Mark

[Author]

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