Forums › Laser Treatment Tips and Techniques › Hard Tissue Procedures › Waterlase – pain during preps
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DoueckDentalSpectatorI have been using hard tissue lasers since Premier Centauri. Altho Waterlase has addressed the problem of the trunk fiber constantly breaking as with the centauri, nevertherless I find that even with a brand new trunk fiber, new G4 tip, recent alignment and checkout by their top technican… it still hurts more than when I prep with an SSWhite Fissurotmy bur. I will be speaking at the Javitts Center, Greater NY Dental Meeting, December 1. I would love to extol the virtues of lasers but I find that the marketing is worth more than the actual usage. If you can make some suggestions I would love to hear.
(Edited by DoueckDental at 12:16 pm on Oct. 9, 2002)
Robert Gregg DDSSpectatorDear Dr. Doueck,
Erbiums are getting better. However, the pain problem you describe if common in mid-infrared wavelength lasers (1500-3500nm). Same with pulsed Holmium YAGs at 2100.
It makes sense that your laser causes the pain right after a tune-up. It’s calibrated to give power at the tip close to what the console reads. That will degrade over time.
Here’ my recommedation. Get an external power meter from Don Dooley at Molectron http://www.molectron.com for about 迀, and calibrate your power at the fiber tip, not the console. A little power variance on hard tissue can mean a lot of difference in pain perception. And lasers can vary 30% from console to tip! Especially as time passes since last calibration.
Bob
I have no $$ interest in Molectron.
AnonymousGuestJacques, welcome to the boards!
Have you had the same sensitivity problems with the nontapered tips?
DoueckDentalSpectatorTapered or not… I still get lots of sensitivity. I was hoping someone could describe their technique for really painfree laser preps
SwpmnSpectatorMy experience has been similar to DoueckDental:
On the first day with the laser trainer standing over my shoulder, we hurt patients. Over the next few weeks we continued to hurt patients using company recommended settings and tips. I kept a log, and over the course of several months my need for anesthesia was 50%.
Use of the laser without anesthetic was so unpredictable that we now routinely anesthetize patients for cavity preps. We no longer market or present the laser as free from anesthetic.
Al
AnonymousGuestGuys, this is what I’ve been doing- understand I’ve just been at this about 2 months now.
Class III – .50 18/18 20 sec
.75 18/18 20 sec
1.0 25/25 20 sec
1.5 30/30 20 sec
1.75 40/40 prep enamel to outline extent of decay. Once enamel removed cut back to .75 18/18 to remove dentin or decay. If lots of decay then use round burr to remove decay and finish up going over prep 1 more time with laser ,then restore.
Class IV and Class V are similar. I’m still experimenting with air water settings but if I ever go above 2 W then I definitely have water and air at least 40/40
I have had more sensitivity with class 1’s but I think I need to raise the water air levels more.
Had to numb 2 class 1’s so far (both just about into pulp) others pt’s have rated sensitivity 3 or 4 out of 10. Always make sure to tell them ahead of time that it may feel cold and if so raise their hand so I can adjust the settings-if they raise their hand I cut back W and increase air /water. Haven’t numbed any pedo yet. Just wanted to add that these settings are with nontapered tips. I find with the tapered , even if I cut W in half I get alot more sensitivity. I’m guessing this has to do with the power density ( am I catching on Bob?)
Hope that helps and if others have better techinique they will share.
SwpmnSpectatorRon:
Thanks for the suggestions. From a practical standpoint, how long does it take you to prepare an average Class III at these settings? Isn’t it like an eternity? That’s what I’ve found using low settings.
Also, doesn’t using a round bur in a slow speed basically negate everything we are trying to accomplish with the laser? One of the main reasons I bought the laser was to get rid of the slow speed which all my patients hate!!!! I tried that round bur technique a few times and it hurts, the patient is like “What’s going on, that’s not a laser???”.
My patients are nervous, scared, hate going to the dentist and don’t want to feel ANY pain. It’s just not practical to ask the patient to raise their hand when they feel pain. If I hurt them they won’t come back and will tell everyone they know.
Al
Robert Gregg DDSSpectatorRon,
Yes, you are catching on! The tapered tip increase the energy density (power relates to time, energy to intensity). So, of course the greater the energy dentisty, the greater the power density over the treatment time as well.
Let’s go though a few things. One parameter that I haven’t seen discussed is the Pulse Duration of your devices. Now, while you cannot select a different PD in your devices, it helps to know what it is and to keep that in mind as you consider which teeth may need anesthetic.
The WaterLase has a PD of 125 microseconds, if I’m not mistaken, whereas the Con Bio DELight has a PD of 250 usec, I think. Now, that might not seem like a lot of difference–and I have argued with many a laser engineer over this, but clinically it is HUGE. This means the intensity of each pulse hitting the tooth with the WaterLase is TWICE that of the Con Bio at identical settings! Wow!!
Another parameter not often thought about or considered clinically is the Repetition Rate or Pulses Per Second (PPS) or Hertz (Hz)–and is relationship to the Peak Power per Pulse you are delivering to tissue.
Let’s look at the following equation:
Average Power (W) divided by Rep Rate (Hz) divided by Pulse Duration (microseconds) = Peak Power/Pulse (W).
So let’s look at two Pulse Durations and two Rep Rates on the effect on Peak Power per Pulse to hard tisue as examples:
125 usec Pulse Duration at 10 Hz and 20 Hz and 1.0 watts Ave. Power
250 usec Pulse Duration at 10 Hz and 20 Hz and 1.0 watts Ave. PowerAverage Power (1.00 W) divided by
Repitition Rate ( 10 Hz) divided by
Pulse Duration (.000125) {10-6 sec} =
Peak Power/Pulse (800 W/pulse)Average Power (1.00 W) divided by
Repitition Rate ( 20 Hz) divided by
Pulse Duration (.000125) {10-6 sec} =
Peak Power/Pulse (400 W/pulse)Average Power (1.00 W) divided by
Repitition Rate ( 10 Hz) divided by
Pulse Duration (.000250) {10-6 sec} =
Peak Power/Pulse (400 W/pulse)Average Power (1.00 W) divided by
Repitition Rate ( 20 Hz) divided by
Pulse Duration (.000250) {10-6 sec} =
Peak Power/Pulse (200 W/pulse)That’s quite a bit of difference in laser intensity delivered to tissue between devices with different parameters, AT THE SAME WATTS AND PPS SETTINGS.
Now this does not answer all the questions related to pain and sensitivity. But I hope this helps better explain that laser tissue interactions are more complex than manufacturers tend to represent and why some proficient users are more adebt , without fully understanding the physics behind their success.
I’ll post another tip later that should help, too.
Bob
PatricioSpectatorI charged off in the beginning trying to drive the laser as fast as the drill. I had some similar problems and got lost in the woods as to what to do. I suggest you take a course from Dr. Chen or someone who can do pain free dentistry. I assure you it is you not the equipment.
I now rarely have problems except with a few skiddish patients. I inject them. When I begin slowly as taught I find on the second tooth and beyond I can speed up with little awareness on the part of the patient. I use high magnification and enjoy watching the preparation develop. I drill all the time when I find the laser to be inefficient for a certain aspect. I use the 1/4 round bur for something almost every prep because I like to and it speeds up things. Afterwords I ask the patient how things went and they do not even know they have been drilled upon. I do use the electric drill which gives a different unfamiliar feel to the patient. This along with a touch of people skill learned the hard way seems to do it.
If you are like I was you bought a piece of equipment but have not sufficiently changed your former approach, concepts, goals and philosophy to comform to micro dentistry. Walk with a master somewhere for a day or two. It worked for me.
Pat Kelly
PatricioSpectatorI charged off in the beginning trying to drive the laser as fast as the drill. I had some similar problems and got lost in the woods as to what to do. I suggest you take a course from Dr. Chen or someone who can do pain free dentistry.
I now rarely have problems except with a few skiddish patients. I inject them. When I begin slowly as taught I find on the second tooth and beyond I can speed up with little awareness on the part of the patient. I use high magnification and enjoy watching the preparation develop. I drill all the time when I find the laser to be inefficient for a certain aspect. I use the 1/4 round bur for something almost every prep because I like to and it speeds up things. Afterwords I ask the patient how things went and they do not even know they have been drilled upon. I do use the electric drill which gives a different unfamiliar feel to the patient. This along with a touch of people skill learned the hard way seems to do it.
If you are like I was you bought a piece of equipment but have not sufficiently changed your former approach, concepts, goals and philosophy to comform to micro dentistry. Walk with a master somewhere for a day or two. It worked for me.
Pat Kelly
AnonymousGuestQUOTEQuote: from Swpmn on 5:28 pm on Oct. 10, 2002
Ron:Thanks for the suggestions. From a practical standpoint, how long does it take you to prepare an average Class III at these settings? Isn’t it like an eternity? That’s what I’ve found using low settings.
Also, doesn’t using a round bur in a slow speed basically negate everything we are trying to accomplish with the laser? One of the main reasons I bought the laser was to get rid of the slow speed which all my patients hate!!!! I tried that round bur technique a few times and it hurts, the patient is like “What’s going on, that’s not a laser???”.
My patients are nervous, scared, hate going to the dentist and don’t want to feel ANY pain. It’s just not practical to ask the patient to raise their hand when they feel pain. If I hurt them they won’t come back and will tell everyone they know.
Al
Al, yesterday I did 2 class III’s (8, 9 -1 moderately deep, the other close to the pulp ~ 1/3 of the tooth gone, pt scared and had stayed away from dentist long enough that she needs 7 surgical ext) Prepped and restored both in 30 minutes.Patient reported nothing uncomfortable. Used a small round bur slow speed to move things along. Small diameter round burrs kept off the DEJ seem to work well, less vibration, and you don’t have to apply alot of pressure which can be misinterpeted by the patient I think you will spend longer prepping than with a high speed but you make up the time not having to wait for anesthesia. I never suggest to my patients they might feel pain but rather that if they feel anything uncomfortable to let me know.I often tell them before beginning that if it gets too ‘cold’ let me know so I can adjust the settings-if they do ,I drop the W a bit. I also tell them the laser will ‘tap’ on their tooth and I tap on the back of their hand to show them. If they ask if I can do this w/o them feeling anything ,I tell them no because even if we did it w/ anesthesia and the highspeed they would still feel vibration, pressure,etc. Be careful not to precondition the patient to the idea of possible pain, I think your confidence in the procedure will make a big difference in how they perceive it.
I’ve been amazed at how aggessively you can use the round bur and the pt will not have any discomfort if you’ve properly ‘conditioned’ the tooth.
I guess I never had the idea that my laser will do everthing a high speed and anesthesia does.
Best Wishes,
SwpmnSpectatorRon Schalter and Pat Kelly:
My hat is off and waving to you guys who have had such success with the Erbium. It’s great that your patients don’t seem to feel the laser and don’t feel or mind a slow speed round bur when they are unanesthetized. Tried mine out today on my office manager after having the laser serviced. Same result, could not remove all of the caries on #7 Class III without anesthesia.
Seems strange to me that dentists could have such a wide range of experience. For information purposes, I’ve had my laser 17 months, use Designs for Vision 2.5 loupes with headlamp and Bien Air electric handpieces.
Al
Glenn van AsSpectatorHi Pat and gang: I agree with what Ron and Pat are saying. When you go to the dental meetings and you see the lasers work you think ……….wow can I cut faster than a drill, no anesthetic. Oh boy , more patients, more money………….then reality sets in.
You have to often on anxious first time users of the laser use low settings and build up.
I had a patient today where I could use 5 watts on her class Vs to get the composite resins out and it was much faster than usual but this is the exception not the rule.
Most of my patients feel something but 80 % rate the discomfort or sensation as being between 1-15 on a scale of 100. 10 % rate it as 15-50 and for them laser dentistry is ok but not unbelievable.
the other 10 % need anesthetic in my practice.
I do know that some people here seem to have more sensitivity than I have when working.
Here are a few tips…….for what it is worth and my opinions come from 3 years of doing this under the microscope….
1. Use lots of water and air.
2. Start low and build up, Rons settings are a good starting point.
3. Dont put the high volume suction to close, the water gets sucked out and doesnt cool the tooth.
4. Dont cut such a narrow trough that the water cant get into the tooth to cool it down.
5. On enamel go across the groove to flatten out the cuspal slopes coming up from the groove.
6. In large open lesions if you use enamel settings , scatter will cause sensitivity on the dentin. You must lower the settings.
7. If the decay tracks laterally, you must either open up the prep wider with a high speed (diamond for instance) or really have a tough time doing it with the end cutting laser. I use round burs sometimes here.
8 In big mushy decay cases I always check the dentinal caries with a small round slowspeed bur. Caries Detector messses up the enamel etching.
9 Soft tissue without water , if you want water, double the energy settings to cut soft tissue.
10. Use silk cord on your class Vs to protect the deeper tissues and serve as a visual marker when you remove the gingival tissue. I will post a case of this in the next couple of days.Dont be afraid to use drills, I do and many people using the laser do.
I try to do anesthetic free dentistry and limit the amount i use the drill.
Those are some tips, hopefully some are new.
Glenn
Robert Gregg DDSSpectatorYeah,
Pat’s got it right. You need to use a “light” touch (pardon the pun) in the beginning when you are trying to avoid using local anaesthetic on hard tissue.
Very nice post Glenn. Great info and good tips! Welcome back from training.
Before I get to my hard-tisse “Tips”, I hope Y’all will appreciate a little perspective on this subject. It’s one I have dealt with for well over a decade using several laser wavlengths and device configurations, including neodymium (1.064 micron), erbium (2.8 and 2.9 microns) and holmium (2.1). I may need Glenn’s flame retartant suit for the following politically incorrect opinions.
Few folks remember, these days, that HARD tissue was the FIRST use of pulsed 1.064 micron Nd:YAGs, by Dr. Bill and Terry Myers in the mid-1980’s and later the rest of us starting in 1989 and to date. And it was (big surprise) the manufacturer (then ADL) that advertised, promoted and HYPED using those Nd:YAG lasers for hard and soft tissue WITHOUT anesthetics. Current advertising practices and clinical advocations are nearly identical to 12 years ago…….Hmmmmmm.
While it was possible to use our lasers without anesthetic to cut nice, clean preps into dentin and diseased enamel with pulsed Nd:YAGs–and could /can VAPORIZE AMALGAM and COMPOSITE–we had many of the discussions and MIXED success that Erbium users mention today–we learned it was not all that predictable, that patients were trying hard to cooperate, but that they were often more uncomfortable than they were letting on.
We eventually learned which teeth and situations were most likely to succeed w/o anesthesia. Generally speaking, it turns out the teeth we were sucessful prepping without anesthesia using pulsed laser anything, were the teeth that we could prep w/o anesthesia using a HS or SP handpiece.
Having said that, I am NOT saying that there are no special advantages or ways to use lasers to prep teeth using “hard” tissue lasers without anesthesia, or as alternative to the drill. It’s just not as easy as the hype makes it sound. There are too many variables between “identical” devices, as I tried to demonstrate in the Peak Power example above, for this to be “Buy laser, turn on Pre-sets, Fire, and Fill”. “Oops! It didn’t work for you doctor?” “Wow, it works for Dr. Guru. Maybe you need some training, some over-the-shoulder demos”…..Same stuff, different companies. Sometimes, it’s still the same Gurus though! Interesting……
I don’t think this is fair to the new laser clinican to be given incomplete info and training. I don’t think it is fair to subject the patients to the new laser dentist with incomplete info and training. And ULTIMATELY, I fear greatly for this wonderful field of laser dentistry to subject the profession to the disappointments of disillusioned dentists who were given incomplete info and instruction.
It takes time, study, skill, patience, some advice, tips, and training. I learned by watching the master, Dr. McCarthy, who can make lasers rotate teeth! OK, I’m kidding. But he would spend HOURS working on a phobic and/or patient “allergic” to anesthesia, use the 1.064 to create anesthesia in a tooth or teeth, remove the decay, prep the teeth with laser and bur and restore. I won’t do that…..I refer them to Del!!! Now, he doesn’t takes hours to prep teeth w/o anesthesia much anymore, but we both take our time. If it starts to take too much time, we numb and prep.
Us “old” laser users eventually came to the conclusion that we bought our lasers to be provide a better service to our patients, and not to hurt them, or titrate our learning curve on them, or experiment on them unnecessarily.
Tip: Using a “3-pulse” on the tooth at first rarely can be felt by the patient. Since some devices have fixed Rep Rates like 20 Hz, you have to develop a “foot-tap” that delivers only 3 pulses. Tap and repeat the 3-pulse at about 1 second intervals. Use your water and air as best the patient can tolerate them.
Yours in Laser Dentistry,
Bob
(Edited by Robert Gregg DDS at 4:10 pm on Oct. 11, 2002)
(Edited by Robert Gregg DDS at 4:18 pm on Oct. 11, 2002)
SwpmnSpectatorGlenn and Bob:
Thanks for your helpful posts. Bob your post was particulary useful in helping me understand my mixed or poor success rate. I’ve long suspected what you said about unanesthetized teeth that can be prepped with the pulsed laser are probably the same ones that can be prepped with the HS or SP(SS?) handpiece.
Glad there is someone else out there that agrees it just aint as easy as the hype makes it sound!!!!!!
Sure glad I found this forum and thank Ron Schalter for creating the forum. Wish I had found the forum earlier!!!
Al
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