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  • #3390 Reply

    Anonymous
    Guest

    Just did my first ‘training’ on the diode. Biolase rep recommended using an activated tip.Treated 2 pockets with activated tip and continuous wave.
    Last night got Manni’s book (thanks for the suggestion Bob) and went thru it kind of quickly.From what I gathered  an unactivated tip seems to make sense in the Tx of perio pockets because you get some action away from the tip whereas an activated tip the action is at the tip so I would have to contact all the areas I wanted to TX. Also instead of CW, pulsed or gated would be better because of the refractory period. I know Bob recommended these things in another post but I want to make sure I’m understanding the rational for this. Is my understandiing correct? Comments?

    Thanks,

    #10811 Reply

    Glenn van As
    Spectator

    Hi Ron actually with the diode you will use BOTH activated and non activated.

    First activate the tip by carbonizing some blue articulating ribbon on the tip to make it a “hot tip”. Then do the gingival curettage part of the procedure where you remove the inner wall of the pocket. This activated tip will remove the inner wall of the pocket and you will get a coagulum on the tip after20-30 secs. Keep the tip moving up and downwards and sideways in the pocket. You will get a fresh bleed when you do this and then you know you are finished with the first step.

    Now cleave the fiber clean and the second part of the procedure (used to be called bacterial decontamination) now referred to as bacterial reduction takes place at different settings.

    If you need further information let me know.

    Glenn

    #10801 Reply

    Anonymous
    Guest
    QUOTE
    Quote: from Glenn van As on 11:30 am on Sep. 20, 2002
    Hi Ron actually with the diode you will use BOTH activated and non activated.

    First activate the tip by carbonizing some blue articulating ribbon on the tip to make it a “hot tip”.  Then do the gingival curettage part of the procedure where you remove the inner wall of the pocket.  This activated tip will remove the inner wall of the pocket and you will get a coagulum on the tip after20-30 secs.  Keep the tip moving up and downwards and sideways in the pocket.  You will get a fresh bleed when you do this and then you know you are finished with the first step.

    Now cleave the fiber clean and the second part of the procedure (used to be called bacterial decontamination) now referred to as bacterial reduction takes place at different settings.

    If you need further information let me know.

    Glenn

    Glenn, thanks for the reply.I appreciate yours and Bob’s patience with all my questions.

    Why not do decontamination with the unactivated tip 1st and then activate the tip and do the curretage? Wouldn’t this decrease the bacteria and not expose the newly lased inner wall of tissue to as great amount of bacteria?
    What about pulsed vs. continuous?

    Thanks again,

    #10814 Reply

    Robert Gregg
    Participant

    Hi Ron,

    You got the general concepts correct.

    Activation = Conditioning = Hot Glass effect = minimal thermal conduction depth penetration if kept moving quickly.

    Non-Activated = non-conditioned = bare fiber = 810nm wavlength emission into tissue and tissue alteration by wavelength dependant absorbtion and protein denaturing (ideally)–or by burning (not ideal).

    Gated pulsed allows for refractory “cooling” but don’t get to confident about it–it warms soft tissue quickly and deep (12mm+)

    Right on, Glenn….you have the technique right.  Crown or crest of tissue preparation first before BC–allows for access to the base of pocket.

    I am fascinated though.

    My partner Del, and I were among the first to advocate this “crest down” technique.  We were certainly the first to publish on this….and we were poo-pooed and told that pocket up was the “established” way….Oh well!
    :shocked:

    I guess I didn’t get the memo that crestal tissue down is now SOC!:wink:

    Good luck Ron.

    C ya,

    Bob

    #10802 Reply

    Anonymous
    Guest

    Did some more reading, so of course , some more questions.

    Bob, you stated in another post that activated tip should be used on fibrous tissue.
    So with an Activated tip – use more for incision (gingivectomy) than treating the goop in the pocket. Is this because of the potential for necrosis 1mm deep with an activated tip(per manni)?or just because the effect is very localized(right at the tip) when kept moving?
    Glenn, in your other post you referred to using an activated tip-was this to do a reverse gingivectomy?
    Thanks

    #10815 Reply

    Robert Gregg
    Participant

    Hi Ron–

    Glad you reading Jeff’s book (http://www.jgma-inc.com/ for those who don’t know about it yet).  Good stuff in their, huh?

    QUOTE
     Bob, you stated in another post that activated tip should be used on fibrous tissue.  

    There’s just no other way to cut–MELT–fibrous tissue like a frenum or fibroma with near-infrared, unless you have VERY high peak powers in a pulsed infrared.  And with a fibroma you ALWAYS want to “lift & undermine” it, not try to vaporize the entire mass.

    QUOTE
    So with an Activated tip – use more for incision (gingivectomy) than treating the goop in the pocket.

    No, not really.  Use the activated tip to incise the internal margin of the pocket epithelium, then continue with it AS LONG AS IT CONTINUES TO REMOVE THE GOOP.  Re-condition, and try again to remove goop.  Better yet, don’t wipe off all the proteins accumulated on the fiber-optic and use that mass as your activator (hot-tip effect).  No more goop?  Then you’re done with that pass.  “More” attempts and fuss in the pocket is not better.

    “Is this because of the potential for necrosis 1mm deep with an activated tip(per manni)?or just because the effect is very localized(right at the tip) when kept moving?”

    The reasoning behind your thoughts and what you are asking, I think, are more to do with the fact the effects of a hot glass effect are very localized in tissue–but still VERY hot!

    Thermal necrosis with the hot glass effect is very localized, unless one spends too much time on thin tissue.  But I think we are talking about pocket therapy.

    EXTENDED or PERIPHERAL thermal necrosis refers to tissue that has been warmed to death (literally) beyond the zone of primary irradiation. Again, in the hot glass mode on the first pass, I don’t think we are talkin with too much concern about that.

    Does that answer your questions?

    Bob

    #10803 Reply

    Anonymous
    Guest

    Yes , its starting to come together. Can I reserve the right to more questions later?smile.gif

    #10808 Reply

    vince
    Spectator

    Hey Bob, Ron, Glenn,

    …have you ever played as a child “monkey in the middle” where the ball gets lobbed back and forth over your head, just out of reach….that’s what this post has been like for me (kinda). I just received the 980 Diode and have also ordered Jeff’s book (thank god).
    Your knowledge amazes me.
    Cheers,
    Vince

    #10806 Reply

    dkimmel
    Spectator

    Vince, I have never played monkey in the middle but I know what you mean. I know I’ve read this post several months back and it is just now making sense. I’ve been reviewing Bob,Ron and Glenns post and not only does their knowledge amazes me but their wellness to share.
    David

    #10813 Reply

    Kenneth Luk
    Spectator

    Hi Vince and David,
    I’ve been that monkey since I joined this forum. Great game, isn’t it?

    Ron,
    What settings are you using with your diode on these pockets?
    I thought you’d be using your Periolase for this treatment. Do you just want to try it out?

    Ken

    (Edited by Kenneth Luk at 11:56 am on July 5, 2003)

    #10804 Reply

    Anonymous
    Guest

    Ken,
    I am using the PeriolaseMVP7 ( this olden days post -Sept 02- just got reactivated by vince) and will not go back to it . My diode is ‘parked’ in my last operatory for my hygienists to use for whitening and for an associate (soon to be a reality, I hope) to use.

    When I was using it for perio I used 1.0CW, activated tip, to deepithelialize and 1.8W 50/50 pulsed, non activated tip, for decontamination.

    Finally, I hope you’re  feeling like…

    monkey.jpg

    …is short lived. Jump in and fire away with the questions as I’m sure others or myself may be wondering about the same thing.

    Rained has stopped, time to get back out on the lake-have a great weekend everyone!

    #10809 Reply

    Don Coluzzi
    Spectator

    Hello: Just a few comments about tip activation with the diode, and especially concerning soft tissue periodontal pocket debridement.
    You always start from the gingival crest and work down to the pocket bottom. Bob Gregg, Del McCarthy and a few of the rest of us old farts were taught by ADL in 1990 to do the reverse, and it made no sense then, and makes much less now. You should first calibrate you fiber extrusion out of the handpiece to the measured pocket depth MINUS 1 mm. Then, remembering to stay on soft tissue (and more precisely on the diseased soft tissue,) move the fiber from the gingival crest down toward the apical portion of the pocket. If you think about it, you can’t easily stay on soft tissue if you start down at the apical extension of the pocket, and you must remember that there’s some depth of penetration of this wavelength beyond the contact area.
    Be very careful with two things: 1) don’t over initiate (not carbonize!) your tip, paying particular attention to avoiding putting carbon on the sides. 2) please clean off as much goop as possible, especially on the sides of the fiber. Otherwise, you can just heat up your endo explorer and accomplish the same thing, which could be some unwanted collateral thermal damage. You already know that diodes only operate either continuously or with very long “pulse” durations, so the thermal relaxation can be minimal.
    Use minimal power settings (I like about 0.3-0.4W. CW) and work quickly.
    Then you can return to the pocket, which is now more of a pool of fresh blood, and perform bacterial reduction with a slightly higher setting (like 0.6-0-0.8W CW) moving faster, like you’re performing hemostasis, again working crown down.
    You can find some articles on this by Nora Raffetto, RDH, who, although she’s one of us veteran laser users, should not be called either old or fart or both. Keep Smiling………..DON

    #10800 Reply

    Anonymous
    Guest
    QUOTE
    Quote: from Don Coluzzi on 11:49 pm on July 29, 2003

    Use minimal power settings (I like about 0.3-0.4W. CW) and work quickly.  
    Then you can return to the pocket, which is now more of a pool of fresh blood, and perform bacterial reduction with a slightly higher setting (like 0.6-0-0.8W CW) moving faster, like you’re performing hemostasis, again working crown down.

    Hi Don,

    I’ve read many people use pulsed for their decontamination/bacterial reduction and was wondering why you prefer CW?

    Thanks for posting and sharing,

    #10810 Reply

    Don Coluzzi
    Spectator

    Hi Ron: Both of my hygienists and I grew up on the pulsed Nd:YAG, and then we got our first diode, the ADT diolase when it first came out, I think about 4 or 5 years ago. That diode has only two buttons–one is CW and the other is a duty cycle of 50%, which is damn near like CW, especially when compared to pulsed Nd:YAG. So, to keep our heads on straight, we just learned to use the diode in CW, and the Nd:YAG as usual. You know that you have to work fast, but once you learn that, you can do quite well. So, pulsed diode works great for bacterial reduction, so if that’s what you learned, go for it, and you should be very successful! One thing to remember is that you’re not removing tissue when you’re preforming the procedure, rather you’re in a pool of blood and fluid. That liquid does act to disperse the heat, so CW isn’t really dangerous. The secret, of course is to get the photons to become absorbed. Hope this helps…….Keep Smilng………DON

    #10816 Reply

    Robert Gregg DDS
    Spectator

    Hi Guys,

    Nice to see you posting Don.  Great to see your expertise here!

    Here’s an interesting poster presentation abstract from the American Association of Dental Research (AADR) meeting in San Antonio, March 12-15, 2003:

    http://iadr.confex.com/iadr/2003SanAnton/techprogram/abstract_27983.htm

    0855 Ablation of Porphyromonas gingivalis in vitro with Pulsed Dental Lasers

    D.M. HARRIS, University of California, San Francisco, USA

    Both pulsed Nd:YAG (1064nm)and continuous diode (810nm) dental lasers are in current use for treatment of periodontitis. It has been shown that laser treatment kills pathogenic bacteria (laser antisepsis), but a quantitative method for determining clinical dosimetry does not exist.

    Objective: The purpose of this study was to develop a method to quantify the efficacy of ablation of Porphyromonas gingivalis (Pg) in vitro for two different lasers.

    Methods: The ablation thresholds for the two lasers were compared in the following manner. The energy density was measured as a function of distance from the output of the fiber-optic delivery system. Pg cultures were grown on blood agar plates under standard anaerobic conditions. Blood agar provides an approximation of gingival tissue for the wavelengths tested in having hemoglobin as a primary absorber. Single pulses of laser energy were delivered to Pg colonies and the energy density was increased until the appearance of a small plume was observed coincident with a laser pulse. The energy density at this point defines the ablation threshhold.

    Results: Ablation thresholds to a single pulse were determined for both Pg and for blood agar alone. The large difference in ablation thresholds between the pigmented pathogen and the host matrix for pulsed-Nd:YAG represented a significant therapeutic ratio and Pg was ablated without visible effect on the blood agar. At threshold the 810-nm diode laser destroyed both the pathogen and the gel.

    Conclusion: Clinically, the pulsed Nd:YAG may selectively destroyed pigmented pathogens leaving the surrounding tissue intact. The 810-nm diode laser may not demonstrate this selectivity due to its greater absorption by hemoglobin.



    My recollection from reading the poster is that pulsed Nd:YAG had a Therapeutic Ratio of Pg leathality of 24 to the 810 diode of 1.5.  That’s a kill rate for pulsed Nd:YAG of Pg that is 16 times greater than CW/gated pulsed 810 diode–and at a depth of 2 mm into the tissues, whereas the CW/gated diode was a surface effect only.  

    The reasons for this are simple:

    1.  True pulsed Nd:YAGs with pulse durations in the 100 millionth’s of a second, have peak powers of 1000-3000 watts per pulse.  That’s also called intensity.

    2.  That sort of intensity with a near-infrared laser will penetrate the gingival tissues to at least a depth of 2 mm, and retain the light dose lethality sufficient to kill pathogens like Pg.

    (Antibiotics penetrate only a few hundred microns)

    3.  Pg–one of the 3 main anaerobic pathogens associated with severe periodontitis and bone loss–is a black pigmented anaerobe that highly and selectively absorbs the 1064 nm Nd:YAG wavelength.

    4.  Pulse “off” times of 49,900 microseconds with pulsed Nd:YAGs allow for beam intensity “extinction” of the pulse intensity–and therefore thermal relaxation of the surrounding tissues, before the next bacteriacidal pulse of 100 microseconds is delivered.

    CW/gated diodes neither have the selectivity, nor the forgiveness factor to the peripheral tissues, nor the intentisty for bacterial lethality to be the optimal device for the treatment of periodontal disease.  But if it is all you’ve got, then it’s better than a hot papper clip for sulcular debridement and sulcular pathologic protein denaturization.

    I prefer that the fiber be longer than the depth of the pocket–so we add a millimeter or 3.  The rationale is that when a fiber breaks–as they do from time to time–the broken fiber will be sticking out of the sulcus.  

    The reason you want it shorter than the pocket depth measurement is when you are using the activated, “hot glass” effect using a diode in order to avoid charring the bone than is quick and certain when using the diode and contacting the bone.  

    Not so with a pulsed Nd:YAG.  You can touch the bone (as long as you don’t hold it in place) and not have any adverse effects.  In fact, one paper published (J Perio I think) stated that Nd:YAG in contact with bone stimulated bone regeneration where CO2 and erbium did not.

    Just my 2 cents…..from an Old Fart!

    Bob

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