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  • #3330 Reply

    Anonymous
    Guest

    Hi all,
    In the last 2 days I’ve had pt’s back for followup decomtamination with the diode. 1 week ago we did  de-epithel. @ 1.0 CW (post molars, did get removal of tissue- clear to slightly white in color- remaining tissue looked normal in color after procedure) ,followed by decont. 1.8  50 duty cycle pulsed (some areas fresh bleed ,but not all). Tx about 15 sec per tooth surface. Didn’t notice any charring or discolorization while doing procedure. Applied vitamin e and gave pt some to apply the next day at home.

    Today both pt’s complained of sore gums . Did decontam today at 1.6  50 pulsed, no anesthesia, ~50% of areas showed bleed . No complaint during the procedure but pt said tetracycle irrigant we used after was very sensitive(probably cold h2o).

    Am I on track here and seeing normal 1 week later or can you offer suggestions?

    Thanks

    #10287 Reply

    Robert Gregg DDS
    Spectator

    Hi Ron–

    What was the rationale for treating the pockets a second time after one week?  Who recommended that to you and what are the clinical study references to support such a methodlogy?

    I mean, I remember when we started out doing pocket “sterilization” (as it was called back then), we were so uncertain of the effects of our lasers in a “blind” procedure, that we did not want the patients numb so that they could report any discomfort (i.e. heat build-up).  

    That was then the thinking 13 years ago, when basic science and clincal studies had not been conducted.   Fast forward a decade:  I hope the laser field has progressed beyond guesswork after all this time.

    The research that Del McCarthy and I have been working on since 1989 has been focused on the optimal near-infrared “light dose” per millimeter pocket depth involved in the treatment of inflammatory periodontal disease.  Our clinical investigations–peer reviewed and published–have demonstrated that is 10 to 16 Joules per mm pocket depth (WITH SOME VERY IMPORTANT EXCEPTIONS).  We treat the pocket ONCE with anesthesia and do NOT re-enter the area for at least 6 months, usually 12 months.  That’s how long it takes for bone and ligament to mature (think implants).

    We have published our protocol several times.  If you want to access them readily they are at <a href="http://www.millenniumdental.com/research.html

    Let” target=”_blank”>http://www.millenniumdental.com/research.html

    Let me know.:)

    Bob

    #10285 Reply

    Anonymous
    Guest

    Bob, I’m sure my answers will be inadequate, but I’ll try.

    QUOTE
    Quote: from Robert Gregg DDS on 5:26 am on Nov. 8, 2002
    Hi Ron–

    What was the rationale for treating the pockets a second time after one week?
    I should have added in my post that the follow up tx is delivered 1mm shorter than the original pocket tx depth and the objective ,as I understand it ,is to just vaporize the bugs at this time, not remove tissue.

     Who recommended that to you and what are the clinical study references to support such a methodlogy?
    This protocol (hopefully, my notes and observations are accurate), come from various presentations at the Biolase symposium in Fla. earlier this year and also from a visit to Bob Barr’s office recently.I’m sure you’ve done enough medline searches  to know what the chances are of finding a study to back this up – at least I haven’t found any – but I’m sure you were asked the same thing when you started using the laser for perio therapy and could not provide any for your wavelength either.

    I mean, I remember when we started out doing pocket “sterilization” (as it was called back then), we were so uncertain of the effects of our lasers in a “blind” procedure, that we did not want the patients numb so that they could report any discomfort (i.e. heat build-up).  

    That was then the thinking 13 years ago, when basic science and clincal studies had not been conducted.   Fast forward a decade:  I hope the laser field has progressed beyond guesswork after all this time.

    The research that Del McCarthy and I have been working on since 1989 has been focused on the optimal near-infrared “light dose” per millimeter pocket depth involved in the treatment of inflammatory periodontal disease.  Our clinical investigations–peer reviewed and published–have demonstrated that is 10 to 16 Joules per mm pocket depth (WITH SOME VERY IMPORTANT EXCEPTIONS).  We treat the pocket ONCE with anesthesia and do NOT re-enter the area for at least 6 months, usually 12 months.  That’s how long it takes for bone and ligament to mature (think implants).

    Does this mean just no entry into the pocket with the laser? or for hyg. recall as well? Sorry its been awhile since I read your published articles (which I really appreciated and have to say were a major influence in my wanting to get involved in using lasers for perio tx. I would also add that if my money were unlimited after buying the Waterlase for hard tissue Tx , that I knew then what I know now,I would have gone your route and laser type and training because from what I have seen your company really has a better handle on the delivery of training.

    We have published our protocol several times.  If you want to access them readily they are at <a href="http://www.millenniumdental.com/research.html

    Let” target=”_blank”>http://www.millenniumdental.com/research.html[/color]

    Let me know.:)

    Bob

    I’ll review the articles again. I had to laugh a little when I read your post this morning ,as last night I had just encouraged more participation in another post .I had also added that people shouldn’t be afraid  to post, because if they were going to get nailed for ignorance ,I’d have gotten it along time ago . Bob, I can tell your words were probably measured in your reply and I appreciate your input and patience with me.  

    #10288 Reply

    Robert Gregg DDS
    Spectator

    Ron–

    Oh my…..I seem to have offended you.  I’ve been given the RED letter treatment!sad.gif

    My apology if I came across as having “nailed” you for ignorance.  That certainly was not my intent.  I know your experience level, and I wasn’t trying to embarass you.  What would be the point?

    I saw and responded to your post about usage.  With 50 members, we are quite a bit more intimate here, and I was trying to get to the essence of your question to better help you out.  I try not to go off “half-cocked” and try to get as much info before I make a statement or recommendation.  Sorry it did not come across more diplomatically.  I thought my smiley face expressed my state-of-mind……..:)

    I really wasn’t measured or restrained at all.  It was late and the Vicodin was wearing off after having the wires yanked out of my heal and Achilles tendon earlier that day……But recovering from surgery gives me lots of time, rest and patience that I don’t usually have when I am practicing full time and not flat on my back.  So my post was “unvarnished” and casual.  Oops.

    That’s how Del McCarthy and I talk to, ask questions and really challenge each other.  We assume nothing–accept nothing–even from each other, to this day unless there is a good rationale.  I brought you into that state of thinking and problem solving.  It had the wrong effect.  Sorry.

    I knew you recently returned from some training.  I was asking questions for an understanding of where you were coming from, who told you what, how, and why you should do certain things, so I could better understand the rationale for the technique you were taught, and what I could recommend.  You know…where you got your information on technique and application and what documentation, references, abstracts, clinical case studies–anything–that was given to you to support it–a Technique Guide, Steps Sequence, Recipe something.  That’s all.  Too bad the written word does not come with intonation and expressions!wow.gif

    It was, I guess a three part question about technique and instruction and written support.  After all, I asked about “clinical study references”, not peer reviewed references, or even published papers.  

    Even when we were all first learning in the early 1990’s–and before espousing any technique, we had folks like Marshall Midda, BdS from UK an internationally renowned periodontist (now deceased), Herb Bader, DDS, MS a periodontist at Harvard, John Horton, DDS, MS a world renowned periodontist from Ohio State, and others like periodontists Steve Gold, DDS, MS, Mario Valardi, DDS, MS and Stuart Epstein, DDS, MS as well as Joel White DDS, MS at UCSF that conducted research into the periodontal use of pulsed Nd:YAGs.  

    So even in the days when research was sparse, we knew these researchers on a first name basis, they presented their ongoing research and preliminary findings at the early pre-ALD meetings.  So we had a basis for doing what we were doing.  These abstracts and papers are available, as are much more recent papers.  I wanted to know if you had been given them in some form or another?  If not, I’ve got them available and could provide them if you weren’t given them…..

    I gain nothing from belittling you or anyone else.  But I come from a perspective on laser periodontal treatment where we have been intensely dedicated to researching and understanding over quite a long period of time.  But aside from our work and publications, it does surprise me that other Educators, Pundits, Mentors, and Gurus who purport to teach laser perio, don’t provide much written support for those claims or written technique guide or a Power Point presentation outline–because I know they do exist.

    Etiquettely challenged,

    Bob

    #10286 Reply

    Anonymous
    Guest

    Bob,
    I guess one of the problems with message boards is that it is sometimes hard to perceive the true meaning behind the words. I wasn’t offended at all and my reply to you used red letters  because that’s the color that was in the ikoncode when I copied and pasted. I actually appreciated the challenge because I know that’s how I’ll really learn things.
    I’m off to dinner now , but later I’ll try and put together some of the things I’ve read and why I felt comfortable following the advice I was given.
    In the meantime why not go back and edit your post as an apology was not necessary,my response was not out of any offense, and I appreciate your explanation and concern about possilbly having offended me.
    AND … anytime you think I’m screwing up and have it coming…. let me have it!

    I also apologize for my post that didn’t come across as intended.It says alot abut your character, that with your knowledge of lasers, you would even be concerned about offending someone with very little knowledge or experience.

    [just remember- as webmaster if  I disagree with any of the posts I can just zap them and make them disappear 😉 – just kidding all!]

    #10283 Reply

    Anonymous
    Guest
    QUOTE
    Quote: from Robert Gregg DDS on 5:26 am on Nov. 8, 2002
    Hi Ron–

    What was the rationale for treating the pockets a second time after one week?  Who recommended that to you and what are the clinical study references to support such a methodlogy?

    Her’e what I’m basing my thinking on;
    In the Dental Clinics of NA there is a review of several studies regarding laser de-epithelialization and  enhanced guided tissue regeneration. The procedures involved an initial flap procedure  and repeated de-epi to prevent down growth of the epithelium thus getting healing from the bottom up rather than top down trying to avoid a long junctional epithelium attachment.
    I think I will skip the charring and external de-epi though smile.gif

    Secondly, other studies show  using decomtamination settings to zap the bacteria should help minimize the inflamation caused by the pathogens  (Inhibitory effect of low-level laser irradiation on LPS-stimulated prostaglandin E2 production and cyclooxygenase-2 in human gingival fibroblasts.
    Sakurai Y, Yamaguchi M, Abiko Y.
    Department of Biochemistry, Nihon University School of Dentistry at Matsudo, Chiba, Japan.http://www.ncbi.nlm.nih.gov/entrez&#8230;.bstract)

    (Bacterial reduction in periodontal pockets through irradiation with a diode laser: a pilot study.
    Moritz A, Gutknecht N, Doertbudak O, Goharkhay K, Schoop U, Schauer P, Sperr W.
    Department of Conservative Dentistry, Dental School, University of Vienna, Austria.)http://www.ncbi.nlm.nih.gov/entrez&#8230;.bstract

    So to kind of sunmmarize-
    1.deepithelialization to remove inflamed tissue
    2.decomtamination (each successive appt 1mm shorter) to zap he bugs, not disturb the healing in the bottom most area to help heal bottom up for better chance of reattachment instead of just a long junctional epithelium
    3. no reprobing for 6 mths so as to not disturb new attachment formation

    Input or sugestions welcome!

    #10289 Reply

    Robert Gregg DDS
    Spectator

    Hi Ron,

    I agree.  Posts can be misinterpretated. Thanks for your explaination.  What should I edit??

    And thanks for your kind words.

    I hate to sound like an “old-guy” when I respond to the posts of new laser users. But sometimes the stuff that I know and do that comes second nature to me, the stuff I don’t even think about anymore, the things I expect others must surely know is not what others know or understand at all!

    I’m not such a sour-puss or Big Head that I ask questions of people just to “nail” them. If I am going to take up my time to be involved in a discussion at all, I’m asking questions with sincerity.

    I know that you appreciate my main concern: justifying (not merely doing something) because some “expert” suggested it, especially now that there is a plethora of research, clinical case studies, abstracts that has been done with nearly every laser that you can imagine. Anecdotes are fine. But I won’t justify–as a reason to experiment on patients or buy a laser–on anecdotes alone. Combined with other information–OK.

    One thing that is always an undercurrent with lasers: We are the fringe of our profession. We’re Orphans. So are medical laser practitioners. After investing so much time, energy, money into this field, I want this technology to flourish in our profession, not be subject to ridicule and scorn.

    I remember when I first got my pulsed Nd:YAG laser in 1990. A lot of press had been whipped up about using the laser for “curettage”. The perio people were furious. A periodontist by the name of Bernard Gantes, DDS. MS from the Long Beach Calif. area wrote a letter that he sent out to all the dentists in my area disparaging this laser for any perio except cutting frenums or whatever. I ran into him at a dental society meeting. In a question not unlike what I asked of you he barked, “What are you trying to accomplish when you perform laser curettage?!” I didn’t have any clue, or rationale, or concept of what I might be doing. But I managed to say, “Trying to maintain my patients’ perio condition.” I guess he was either too angry to pursue the question, thought I was too ignorant (I was of perio then) or I made a good come-back he couldn’t respond to because he just turned and walked away.

    Talk about people who want to “nail” you it is certain periodontists!! See President’s Newsletter and the responses, as well as the other newsletters attached. <a href="http://www.calperio.com/calperio/csp.nsf/vpages/News?OpenDocument

    They” target=”_blank”>http://www.calperio.com/calperi….

    They are lying in wait to ask you what your justification for using lasers in the perio pocket might be. We have a lot more data, rationale, and scientific justification than we did when Gantes questioned me.  That’s where I was coming from when I asked you those questions.

    Your friend,

    Bob

    #10284 Reply

    Anonymous
    Guest

    Bob,
    Can you recommend research sources ,besides PubMed?
    Thanks

    #10290 Reply

    Robert Gregg DDS
    Spectator

    Hi Ron–

    I can’t quote in RED!

    QUOTE
    Her’e what I’m basing my thinking on;
    In the Dental Clinics of NA there is a review of several studies regarding laser de-epithelialization and  enhanced guided tissue regeneration. The procedures involved an initial flap procedure and repeated de-epi to prevent down growth of the epithelium thus getting healing from the bottom up rather than top down trying to avoid a long junctional epithelium attachment.
    I think I will skip the charring and external de-epi though  

    OK,  This is a good start.  But let’s not ingore the charing and the external de-epi though.  You may want to turn down the settings, or use a gated pulse.  Alternatively, you may want to try creating a hot-glass effect for the first pass, then turn down the power and pulse.

    I like the references you listed to give a rationale for laser pocket use.  It’s a good start.  You want to be able to explain/justify to patients, non-laser peers, state-boards, plantiff’s lawyers, peer review committees, etc.

    QUOTE
    So to kind of sunmmarize-
    1.deepithelialization to remove inflamed tissue
    2.decomtamination (each successive appt 1mm shorter) to zap he bugs, not disturb the healing in the bottom most area to help heal bottom up for better chance of reattachment instead of just a long junctional epithelium
    3. no reprobing for 6 mths so as to not disturb new attachment formation

    You didn’t mention if you used anesthesia or not.  It’s harder to remove all the pathologic proteins and epithelium and bugs in one treatment without profound anesthesia to get a good clean & kill-rate.  But you will need to be careful in learning your safe and effective laser dosimetry, maybe, before you can do that.

    As a rule, the only reason to re-enter the pocket after initial treatment, is if there is bleeding, inflammation or re-current disease–not for “decontamination” unless there was a reason for killing the bugs first appointment.

    With diodes, a re-entry protocol may indeed be required.  But if you can avoid it, your results will be better.  Wounds don’t like to be picked at or stirred up.  They want to be left alone to heal.  (Just ask my ankle!)

    Best kept secret in laser dental research:

    http://www.spie.org/app/Publications/index.cfm?fuseaction=advsearch

    But have you seen this one??

    <a href="http://spie.org/scripts/abstract.pl?bibcode=2002SPIE%2e4610%2e%2e%2e49H&page=1&qs=spie

    Bob” target=”_blank”>http://spie.org/scripts&#8230;.e

    Bob

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