PRACTICAL GUIDE AND CLINICAL PROTOCOLS WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 1BENEFITS OF THE DIODE LASER Laser technology represents an evolution of medical techniques and an indispensable daily support to the traditional dental practice. The Wiser laser is equipped with a series of pre-set programs, conforming to average settings certified by many scientific publications and collaborations with prestigious Universities, with doctors and experts of the field, These pre-set values can be changed at any time in the advanced mode BENEFITS OF THE DIODE LASER COMPARED TO CONVENTIONAL TECHNIQUES. The extreme tolerability of the treatment can reduce the need for anaesthesia in most operations. This assures a better relationship with the patients, especially the odontophobic and children. The laser is a less invasive method compared with the conventional techniques, offering thus little cell destruction and little bleeding thanks to its haemostatic properties. The laser has a strong power against bacteria thus encouraging decontamination and anti-inflammatory action while using it. The treatment with the laser requires a reduced number of sessions, and a shorter chair time for most applications. BENEFITS FOR THE DENTIST + Practice growth and differentiation * Precise incision, excision, ablation * Quality of work + Clean, clear operating field + Reduced stress * Greater through-put of patients * Increment revenue * Greater efficiency + Fibre provides better access * Visibility in oral cavity + Versatile tool for several applications WISER ~ practical guide and clinical protocols BENEFITS FOR PATIENTS. + Minimal or no bleeding + No swelling, Faster healing + Reduced post-operative infection + Minimal or no anaesthesia + Minimal pain, inconvenience *Less time in chair, Less anxiety + Whitening - single visit procedure +High quality treatment *Less time predictable result + May be used during pregnancy and in pacemaker wearers AMNII40.3 March 2017 2LASER PARAMETERS This brief explanation of the parameters involved in the diode laser will help the dentist approach and understand the benefits of laser assisted treatments. POWER the amount of energy over time emitted by the laser. It is measured in Watts (W):1 Watt equals 1 Joule per second. TIME: application time for each single treatment. MODE: two emission modes are used for dental lasers, continuous and pulsed. Continuous wave mode refers to a laser which produces a continuous beam output. Fast in cutting procedures, has high haemostasis, but may create a little necrosis on tissue ue i> In the pulsed mode the laser produces peaks of power at short intervals of time. In the pulse mode, the average output power is lower than the peak of power proportionally to the duty cycle percentage. The most common Time On and Time Off is variable from 20s up to 10ms. The pulsed mode is slower than CW in cutting procedures but avoids necrosis on tissue. FREQUENCY is the measurement of the number of wave oscillations (pulses) per second. It is measured in Hertz (Hz) The combination of the frequency and the Time On and Time Off characterizes the pulsed emission. It has two important clinical advantages: 1 allows (during the time off) thermal relaxation and therefore no heat accumulation by the tissues. 2. In micro-surgery there will be less use of anaesthesia, avoiding inconveniences to the patient, WARNING: Use your clinical judgement to determine all aspects of treatment including but not limited to the pre-set laser treatment. Closely observe and monitor clinical effects and use your judgement to determine the correct approach for the operation WARNING: please note that these parameters have been determined on average standard cases based on clinical feedback from experienced laser dentists. The laser parameters saved as pre-set programs can be changed and saved in the advanced mode, WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 3PRACTICAL LASER SUGGESTIONS Tip Movement: Hold the end of tip perpendicular to the tissue, vaporise the mucus surface by moving the tip lightly around the required tissue area. Place the tip termination into direct contact with the required area and move it back and forth over the tissue with rapid, decisive and regular movements. Should the patient feel any discomfort, cool the operative area with the help of cold air. Do not hold the tip termination against the tissue zone for extensive time to avoid the risk of necrosis and superficial damaging. Always keep the tip in movement during operation Cleaning the tip termination: Regularly clean the tip termination by inserting it and rubbing it several times along a damp cotton swab to eliminate any carbon residue. This procedure ensures optimal power output. Activating the tip: Some surgical treatments require tip activation. Verify if activation is necessary in the protocol. To activate the tip, switch on the laser beam and direct it for a few of seconds against a dark coloured scrap of paper. POSSIBLE SIDE EFFECTS WARNING: The improper use of this laser device might lead to unwanted, sometimes dangerous effects. The laser has many beneficial effects on human tissue given the correct values of power, frequency and application time. With high values of power and other inappropriate parameters it may though cause either undesired vaporization or necrosis in the radiated tissue. Should necrosis be desired, as in cases such as photodynamic therapy or in the equivalent use of the scalpel, it will be unavoidable that along with the targeted tissue, the closest surrounding tissue might be damaged as well. The extent of such harm is essentially determined by the energy density provided to that tissue and exposure time. In many cases the harm will turn out as light and tolerable compared to the benefits. The user should therefore very attentively check the following parameters, in order not to cause undesired effects on the patient Power Diameter of the tip Distance between the end of the tip and the tissue spot Continuous or pulsed laser emission Application time WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 4IMPORTANT SAFETY PRECAUTIONS Individual safety in the working area The most dangerous hazard that can arise from a wrong application of laser light is damage to the retina if it is directed towards the eyes without adequate protection. Doctor, patient, assistant and all others inside the operating room must wear appropriate laser eye protection for the diode laser. Laser Plume Suction Use suction as required to maintain a clear view during treatment. Special care must be taken to prevent infection from the laser plume generated by vaporization of virally or bacterially infected tissue. Anaesthesia In soft tissue cases anaesthesia may not be required, however patients should be closely monitored for signs of pain or discomfort at all times. = Operation area Wiser laser is developed to remove soft tissues. Therefore always be aware of adjacent structures and substructures during treatments. Exercise extreme caution when using this laser in pockets or channels where critical structures could be damaged. Do not direct the laser beam towards amalgam, gold or other metallic surfaces. SAFETY The major risk involved in improper exposure to laser light is the risk of serious damage to the retina, For this reason it is necessary to always wear adequate eye protection during use Inappropriate use of the laser device may cause unwanted and sometimes dangerous consequences. To ensure that the laser equipment is used correctly and that all possible risks to health are properly addressed, it is necessary to provide clinic personnel with adequate safety training. An individual designated as the practice Laser Safety Officer (SO) has the authority and responsibility to monitor and enforce the control of laser hazards and to evaluate and control the laser hazards present In particular, the aim of the safety training given to employees is to ensure that all the people working in clinic with laser units are . competent in the operation and control of laser units * aware of the health hazards that can arise from inappropriate or improper use of the equipment; + understand the meaning of warning signs and other safety instructions; . know how to use the safety equipment provided. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 51. ENDODONTICS 1.1 ROOT CANAL DECONTAMINATION POWER TIMER Ton Toff TIP. 25 W Ss 10 ms 10ms Blu (not activated) After completing the traditional preparation of the canal, insert a paper cone lightly soaked with hypochlorite. Carefully measure the length of the canal and transfer the exact length to the tip. It should be inserted all the way (without activating the laser) to the top until 1mm from the apex. 1° Laser session Start lasing with rotating movements in a clockwise direction towards the opening After the first laser session, rinse the canal with a 10% citric acid solution. Leave the canal wet. 2° Laser session Reinsert the tip and again with rotating movements, but this time in an anticlockwise direction towards the opening. After the second laser session, rinse the canal with hypochlorite. 3° Laser session Repeat again the last laser session. The combination of laser with hypochlorite bring to a complete sterility and crystallisation with closure of the dentinal tubules of the canal. Proceed with the closure of the canal using traditional methods. Remember that the laser can be used to cut and reheat the gutta-percha. Contact with the material could be at max 2-3 seconds to avoid elevated increases in temperature, WISER ~ practical guide and clinical protocols. = AMNII40.3. March 2017 61.2 PULP CAPPING POWER TIMER Ton Toff TIP O.7Ww 10s cw cw Blu (not activated) This procedure is useful to temporarily uncover a small portion of the pulp chamber that will be exposed and frequently bleeds. With the laser it is possible to decontaminate and coagulate the exposed coronal pulp in order to aid the direct pulp capping with greater success. The cavity must be cleaned with a cotton bud soaked in chlorhexidine 2%, so that the treated surface is well visible. A slight 8-10 second compression will limit bleeding if present Place the tip 2mm from the exposed pulp: approach the exposed pulp opening with regular back and forth movements for a superficial and delicate vaporization and haemostasis. Initial power is 0,7W, with a slight pressure on the tip of the fibre. Touch the pulp rapidly with quick laser spots, by tapping the pedal for a few seconds. For complete decontamination extend the treatment then over 2-3mm around the opening. Use chlorhexidine based disinfectants to prepare the cavity and follow immediately with the direct capping. 1.3 APICOECTOMY DECONTAMINATION POWER TIMER Ton Toff TIP. 15W 10s cw cw Blu (not activated) Though the diode laser is used more on soft tissue, it can be used to decontaminate the apical area. In continuous mode, keep the tip in movement over the area without contact, in order to avoid over-heating, Irrigate the cyst cavity with physiologic saline solution between 10 s lasing sessions, for a total of 2 minutes, with 10 s pause in between sessions). It is also possible to decontaminate using the PDT protocol with hydrogen peroxide 3% - 10 - volume (see therapy section). WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 72. PERIODONTICS 2.1 LASER ANALGESIA POWER TIMER Ton Toff TIP. 1W 20s CW CW Biotip The diode laser can induce temporary local analgesia because it inhibits the frequency of the firing of the peripheral nociceptors, therefore raising pain threshold Laser radiation determines the hyper-polarization of the membrane near the nerve fibres, secondary to the iso-orientation of the surface lipoproteins, that consequently selectively close the Na*/ K* canals, therefore limiting the transmission of sensitive stimuli in the radiated area. Such a temporary state of localized analgesia is of great advantage before any surgical procedure, or when the injection of anaesthetics is not necessary or before the injection in order to avoid the pain of the needle in children. Use the contact biostimulation accessory (biotip) for a total of 2 minutes WARNING: do not autoclave biostimulation accessories. 2.2 POCKET DECONTAMINATION POWER TIMER Ton Toff TIP 25 W 30s 30us 70us Yellow (not activated)) Record the depth of the pocket and evaluate its condition. Use the periodontal probe to define the height of contour desired. Insert the tip termination in the bottom of the periodontal pocket, pull it out Imm, and then start lasing, keeping the tip parallel to the root surface and move it in a fan shape both in vertical and horizontal directions covering both the epithelial surface and connective tissues. Keep the fibre slightly tilted towards the root cementum and then toward the granulation tissue in the pocket. Once inside the pocket, position the fibre so that it sits lightly on the gum to irradiate the root cementum. Then tilt it towards the crown to direct the laser to the granulation tissue of the pocket. Each application lasts for 30 seconds. Between applications irrigate the treated sulcus with hydrogen peroxide. Repeat the sequence three times for each pocket. The greater the periodontal damage, the more carbonized granulation tissue must be removed from the tip, with a damp gauze. Vaporizing the necrotized tissues eliminates the bacteria, therefore obtaining better decontamination compared to only scaling and root planing. Repeat treatment after 10 days. The number of sessions needed depends on the gravity of the periodontal disease and on patient response to treatment. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 82.3 BIOSTIMULATION POWER TIMER Ton Toff TIP. 0,7W 20s cw cw Yellow (not activated) or Biotip For this treatment use either the yellow tip or the contact biostimulation tip. In the first case, the tip must be used defocalized i.e. not in contact with the tissue. In the second case, the biotip must be kept in direct contact with the treated tissue. Treat the area for 20 seconds, 2-3 times per area (or quadrant) in order to distribute the energy evenly over the entire area. The low power defocalized laser beam is effectively absorbed by the tissue and will stimulate metabolic processes and tissue regeneration, thanks to the photo-chemical effects of laser light. No alterations of the tissue will take place, only an antalgic effect (inhibition of the firing of the peripheral nociceptors) and the acceleration of the healing process in wounds (photo-enzymatic induction). The increase of t seed in the Krebs cycle induced by the laser determines and increase in the production of ATP and a more frequent cellular mitosis in the irradiated area, 2.4 GINGIVAL RECESSION POWER TIMER Ton Toff TIP o.5w 20s cw cw Yellow (activated) + Biotip Gingival recession can be caused by diverse factors: periodontal disease, genetics, aggressive dental hygiene, hormones, smoking, or bruxism. The progressive retreat of the gums gradually expose the tooth and its root to the aggression of bacteria and consequently caries. The diode laser can reduce the problem by blocking its development and stimulating its repair. Begin with a light de-epithelization of the gingival contour for 6-7mm with the yellow tip. Then biostimulate the area for one minute with the contact biotip. Repeat the treatment once a week for a total of 4-5 sessions. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 93. SURGERY 3.1 SURGERY GRANULATION POWER TIMER Ton Toff TIP 15W == cw cw green (activated) APPLICATIONS: operculums, implant uncovering, frenectomy, clinical crown lengthening, gingivectomy, fibroma removal, epulids, gingival hyperplasia. Usually anaesthetic is not necessary but a topic anaesthetic can be applied locally. Treatments begins by vaporizing the tissue starting from the lowest power setting of the granulation tissue treatment. The fibre must be activated and held perpendicular, in contact with the granulation tissue (contact must be light and the pressure on the tip slight). Movement must be fast and repeated so that the tissue is vaporized layer by layer. If the patient feels discomfort, cool the area using the air unit at a 5cm distance. In the case of a biopsy, irrigate with physiological solution to limit dehydration or carbonization along the cutting line. On more vast areas or on fibrotic tissue, use the Normal Surgery mode, or the Fibrotic mode for greater cutting power. In this case, laser analgesia is recommended: irradiate at a 1 cm distance (not in contact, for 2 minutes, 0,7to 1W, CW) to the firing of the peripheral nociceptors. If necessary dab the area with cotton soaked in anaesthetic between laser sessions. Should the patient still feel pain, a minimal dose of anaesthetic without vasoconstrictor may be injected. 3.2 SURGERY NORMAL POWER TIMER Ton Toff TIP 7W = 50 um 1ms green (activated) APPLICATIONS: operculums, implant uncovering, frenectomy, clinical crown lengthening, gingivectomy, fibroma removal, epulids, gingival hyperplasia Usually anaesthetic is not necessary but a topic anaesthetic can be applied locally. Treatments begins by vaporizing the tissue starting from the lowest power setting of the granulation tissue treatment. The fibre must be activated and held perpendicular, in contact with the granulation tissue (contact must be light and the pressure on the tip slight). Movement must be fast and repeated so that the tissue is vaporized layer by layer. If the patient feels discomfort, cool the area using the air unit at a 5cm distance. In the case of a biopsy, irrigate with physiological solution to limit dehydration or carbonization along the cutting line. On more vast areas or on fibrotic tissue, use the Fibrotic mode for greater cutting power. In this case, laser analgesia is recommended: irradiate at a 1 cm distance (not in WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 10contact, for 2 minutes, 0,7 to 1W, CW) to the firing of the peripheral nociceptors. If necessary dab the area with cotton soaked in anaesthetic between laser sessions. Should the patient still feel pain, a minimal dose of anaesthetic without vasoconstrictor may be injected CAUTION: for maximum cutting speed and efficiency, regularly clean the tip with a damp gauze in order to remove any tissue residue 3.3 SURGERY FIBROTIC POWER TIMER Ton Toff TIP. 7W - 10 ms 10 ms green (activated) APPLICATIONS: operculums, implant uncovering, frenectomy, clinical crown lengthening, gingivectomy, fibroma removal, epulids, gingival hyperplasia Usually anaesthetic is not necessary but a topic anaesthetic can be applied locally. Treatments begins by vaporizing the tissue starting from the lowest power setting of the granulation tissue treatment. The fibre must be activated and held perpendicular, in contact with the granulation tissue (contact must be light and the pressure on the tip slight). Movement must be fast and repeated so that the tissue is vaporized layer by layer. If the patient feels discomfort, cool the area using the air unit at a Scm distance. If this is still not sufficient to ease discomfort, laser analgesia is recommended: irradiate at a 1 cm distance (not in contact, for 2 minutes, 0,7to 1W, CW) to the firing of the peripheral nociceptors. If necessary dab the area with cotton soaked in anaesthetic between laser sessions. Should the patient still feel pain, a minimal dose of anaesthetic without vasoconstrictor may be injected. In the case of a biopsy, irrigate with physiological solution to limit dehydration or carbonization along the cutting line. CAUTION: for maximum cutting speed and efficiency, regularly clean the tip with a damp gauze in order to remove any tissue residue WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 i3.4 COAGULATION POWER TIMER Ton Toff TIP 2w - cw cw green (not activated) "Thermal" lasers like the diode laser yield perfect haemostasis thanks to their coagulative properties. The diode laser can thus be used to control haemorrhages that occur during conventional surgery (use of a scalpel) Begin by cleaning the wound and removing the blood with a sterile gauze. Then lase over the wound by pecking quickly over the bleeding area. The time necessary depends on the size of the area. If bleeding does not stop after a few passages, a vessel with a diameter greater than 0,5 mm is probably involved. In this case use alternative techniques 3.5 GINGIVAL TROUGHING POWER TIMER Ton Toff TIP 1W - cw cw green (activated) Usually anaesthetic is not necessary but a topic anaesthetic can be applied (lidocaine spray 10%). If the patient still feels pain, decrease the power (not less than 0,6W) Place the tip of fibre in the entry to the crevicular crevice, respecting the gingival margin of the periodontium. Direct the laser beam towards tissue that needs to be removed and vaporize the gingival perimeter without touching the edges of the stump. Remove the minimal quantity of tissue necessary to aid the taking of the impression, and avoiding the use of a retraction cord. Since bleeding will not occur the impression will be precise and clean. Always keep the tip clean during use by removing residue with a damp gauze, or by inserting it in a cotton roll and activating the laser beam inside. To obtain a result similar to that of a “double’ retraction cord, after this procedure, pass over the through with an endodontic tip (blue — activated) with the same procedure but with power at 0,5W. 3.6 GINGIVECTOMY POWER TIMER Ton Toff TIP 15W - cw cw green (activated) Usually anaesthetic is not necessary but a topic anaesthetic can be applied (gel or spray). If infiltration is necessary, use an anaesthetic without vasoconstrictor. Begin treatment by vaporizing the tissue with minimum power values of 1,5W. The WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 12activated fibre must be kept in contact with the tissue with a slight pressure. Use quick and regular movements in order to lase the tissue layer by layer. If necessary increase power to 1,8-2W. Keep the area cool with the air flow, kept at 1-2 cm distance. If lasing larger areas or more fibrotic tissue, increase power to 2 W. To remove fibromas refer to the specific protocol 3.7 FRENECTOMY POWER TIMER Ton Toff TIP 15W - cw cw green (activated) Anaesthetic may not necessary but the use of a topic anaesthetic is suggested, especially with sensitive or non-collaborative patients. Begin with a minimal power of 1,5W, keeping the tip tilted at a 45° from the frenulum. Vaporize the tissue with light and rapid movements. If the patient does not feel pain, increase to 2W for more effective cutting. To cool the area use the suction unit at a 1-2mm distance. In some cases, it may be useful to irrigate with a saline solution to avoid dehydration or carbonization. The absence of bleeding with keep the operation field visible. Sutures are not necessary since healing will occur by secondary intention. It is important to teach the patient to exercise the lip (pulling the upper lip with the index finger and thumb of both hands) or the tongue (extensions) to avoid reattachment, with healing that must occur by secondary intention. 3.8 HYPERPLASIA POWER TIMER Ton Toff TIP 2W - cw cw green (activated) Hyperplasia, also known as gingival enlargement, can be a serious complication in dentistry since it can compromise proper dental hygiene and lead to gingivitis. It is also an important aesthetic problem. The diode laser can solve this condition with a minimally invasive approach. Anaesthetic may not necessary but the use of a topic anaesthetic is suggested, especially with sensitive or non-collaborative patients. If infiltration is necessary, use an anaesthetic without vasoconstrictor. Being lasing with the basic power setting (2W) keeping the tip perpendicular to the gum Use quick, light movements on the treated tissue. To cool the area use the suction unit at a 1-2mm distance. In some cases, it may be useful to irrigate with a saline solution to avoid dehydration or carbonization. The absence of bleeding with keep the operation field visible, Sutures are not necessary since healing will occur by secondary intention. 3.9 ABSCESS POTENZA TIMER Ton Toff TIP. 2W - 10ms 10ms green (activated) The diode laser can cut the abscess almost painlessly. By decreasing power or using a topic anaesthetic, it is possible to control pain during operation. Laser analgesia treatment is suggested before beginning (see protocol — not in contact — 2 minutes at 0,6W — CW). WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 13Vaporize the surface mucosa keeping the fibre perpendicular to the area, lightly brushing but not applying pressure, to not cause pain. Create a Imm access and proceed with the drainage. It is also possible to enter the abscess cavity directly with the fibre to ensure optimal draining and decontamination by moving the fibre in a fan motion. It is important to operate quickly. Avoid directing the laser beam toward the periosteum (the heat will cause pain). Use air to cool the area if the patient feels pain, but avoid its entry in the abscess cavity. Use a damp gauze to clean the tip regularly in order to remove any carbonized tissue residue. The scarce bleeding will allow drainage without compression, thus reducing the risk of problems linked to stagnation. 3.10 FIBROMA POWER TIMER Ton Toff TIP. 15W - cw cw green (activated) The excision of the fibroma with the diode laser is performed with precision by lasing with quick movements around the border of the lesion, pulling it perpendicularly with tweezers at the same time. The slight traction determine a precise and correct cleavage plane while lasing with the tip of the fibre held at a 45° to the axis of the lesion and to the tissue plane. The duration of this procedure depends on the size of the lesion, especially its extension at the base. Cool with air flow it the patient feels pain. If the fibroma is large and its excision complex, proceed with an infiltration of anaesthetic without vasoconstrictor. Clean the tip frequently with a damp gauze for fast and effective cutting. The fibroma can be removed with the tip and the wound will heal by secondary intention. Healing and complete re- epithelization will take 10 days WARNING: if histopathological evaluation is required, it is important to inform that the excision was carried out with a diode laser to avoid possible diagnostic problems 3.11 GRANULOMA POWER TIMER Ton Toff TIP 15W - cw cw green (activated) In some cases, the presence of granulation tissue inside a large cavity may hinder the access to the pulp chamber because the bleeding of the inflamed tissue limits visibility. With the diode laser it is possible to vaporize and coagulate the granulation tissue inside the pulp at the same time, so that the canal therapy results easier, and the reconstruction of the element can be carried out. The laser is also useful in the case of periodontitis, when often fistular openings that appear in the fornix lead to the formation of granulation tissue. Treatment of the fistula is not recommended since it is necessary to monitor the state of the infection (it will spontaneously close once the infection that has generated it heals), but the removal of WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 14the granulation tissue is convenient since it will avoid heavy bleeding or any other cause of trauma (during chewing for example). Usually anaesthetics are not necessary. Vaporize lightly holding the tip at a 45° angle from the growth, in order to keep the area clean and favour healing, thanks to the haemostatic effects of the laser IMPORTANT: without causal treatment of the fistula, a relapse will occur and new granulation tissue will form at the fistula opening. 3.12 FISTULA POWER TIMER Ton Toff TIP. 15W - cw cw green (activated) This protocol is based on intraluminal coagulation: the tip is inserted in the fistula until it reaches the end of the tunnel. Begin with a few shots before starting the treatment Lase the fistula canal as you pull out the tip. The correct speed of retraction is given by the water vapour that must be barely visible, When the tissue begins to appear white, coagulation has begun. Continue the treatment by decreasing power and conclude when it has whitened completely. Eliminate the plume with air suction. Conclude treatment by coagulating the external part without direct contact In the following days rinse with hydrogen peroxide (3%-10 vol.), to avoid bacteria colonization. Note: this treatment is aimed at the closure of chronic fistulas that are not completely solved, even after the original inflammation has healed. In case of ongoing infection, (endodontic, periodontic or osteitic) fistula treatment is not recommended, since it represents a natural monitoring of the infection. The fistula will close spontaneously only when the septicity has healed, even without treatment WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 154, IMPLANTS 4, IMPLANT UNCOVERING POWER TIMER Ton Toff TIP 2.4W - 20 us 20 us white (activated) Anaesthetics may not be necessary, but a topic anaesthetic can be applied (gel or spray) or the power setting decreased. Faster movement and frequent pauses will avoid the overheating of the implant or the surrounding bone and favour tissue conditioning. After locating the implant (through the mucosa with a straight probe) lase with the tip in direct contact, perpendicular to the surface. Begin by vaporizing the portion of mucosa overlying the implant with circular movements, stating from the centre, towards the outer part. Circle the perimeter precisely and remove the tissue. Proceed with circular movements keeping the tip at a 45° angle and move towards the outer part until the implant is completely exposed. Do not linger over the implant to avoid heating that may cause pain or thermal damage. Clean the area with a cotton pellet and hydrogen peroxide or saline solution to remove any trace of residue or carbonization 4,2 PERI-IMPLANTITIS POWER TIMER Ton Toff TIP 2,5W 30s 30 us 70 us white (not activated) Insert the tip at the base of the periodontal pocket beside the implant, and begin lasing by holding the tip parallel to the surface of the implant. Move the handpiece vertically and horizontally to cover both the epithelial and the connective tissue of the gum Vaporize the granulation tissue to eliminate bacteria. Clean the tip frequently with a damp gauze to remove any coagulated tissue. Each treatment should last 30 seconds. Once terminated, irrigate the pocket with hydrogen peroxide (3%-10 vol.). Repeat the procedure three times. If the patient feels pain, move the tip more rapidly. Therapy ends when a slight bleeding in the pocket occurs. The number of sessions necessary depends on the gravity of the infection. In general, a complete procedure every 10 days for the first month, and once a month for the following three to five months is recommended. Healing can be improved with the use of the biotip, to biostimulate the tissue from the outside of the pocket. Note: do not linger with the laser tip in contact with the implant to avoid heat build up and pain for the patient. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 164,3 BIOSTIMULATION POWER TIMER Ton Toff TIP. 0,3W 60s cw cw white (not activated) With low power, in continuous mode (CW), the thermal effects of the laser can be used to biostimualte the peri-implant sulcus by lasing the perimeter of the implant with circular movements. This treatment is complementary to the treatment of peri-implantitis and can also be done as prevention during the periodical visits of implant patients. The benefits of such a treatment will be visible both on the hard and soft tissue that surrounds the implant. 4,4 ALVEOLAR DECONTAMINATION POWER TIMER Ton Toff TIP O.5W 60s. cw cw white (not activated) This protocol can effectively decontaminate post-extractive dental alveolus to avoid infection. At the same time an effective biostimulation will favour the healing of the area and reduce post-op recovery. Insert the tip inside the dental alveolus and lase over the entire area, holding the tip at a 2-3 mm distance from the surface, thus defocalizing the laser beam. Use circular movements beginning from the inner centre of the alveolus, towards the gingival margin The procedure is even more effective when used in combination with hydrogen peroxide (3%-10vol.). WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 175. THERAPY 5.1 HERPES POWER TIMER Ton Toff TIP 12W 60s cw cw black (not activated) Since the areas usually affected by herpes are very sensitive, begin with a laser analgesia treatment (0,6W power, CW mode for 120s), with the beam defocalized, using grazing movernents over the entire lesion. The actual treatment consists in lasing with the preset parameters, the beam defocalized (tip held at 2mm from the surface), over the entire affected area, and 2mm, beyond the perimeter of the lesion After two minutes of treatment, the patient will feel a sort of paraesthesia. Now it is possible to operate with the tip in direct contact to lightly vaporize the surface, which will change from the open lesion blister phase to the crusting phase, with clear evidence of forced dehydration Should the patient feel discomfort during treatment, use the air spray at a Scm distance from the tissue to cool the area between each passage. The patient may feel pain at the end of treatment, that will only last 5-10 minutes. 5.2 APHTAE POWER TIMER Ton Toff TIP 1w 60s cw cw black (not activated) Begin by lasing over the lesion with the tip at a 2mm distance from the tissue (defocalized). Proceed by lasing the lesion in a circular motion, also 1 mm beyond its border. After the first minute proceed by lightly touching the surface with the tip, while lasing for 5 seconds, using paint brush movements. If the patient feels pain, avoid direct contact. Treatment can be concluded when the lesion changes visibly. The patient may feel pain at the end of treatment, that will only last 5-10 minutes. 5.3 CHEILITIS POWER TIMER Ton Toff TIP. 0,9W 60s cw cw black (not activated) Since the areas usually affected by angular cheiltis are very sensitive, begin with a laser analgesia treatment (0,6W power, CW mode for 120s), with the beam defocalized, using grazing movements over the entire lesion. Begin treatment by lasing over the area for 1 minute, with the beam defocalized, the tip a 2mm distance. Proceed by placing the tip in contact, perpendicular to the lesion, and lasing with slow and light movements for 5-10 seconds, over the lesion and 2mm beyond. Tip movement must be light and slow, like a brushing movement, with very brief contact. For larger and more severe lesions, apply xylocaine 5% cream, and use air during treatment if the patient feels pain. In case of discomfort when the tip comes into contact, use quick and regular touching movements. The patient may feel pain at the WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 18end of treatment, that will only last 5-10 minutes. Treatment should be repeated every three days for two weeks. Healing will depend greatly on the patient, that must not open his/her mouth excessively to avoid reopening of the wound. 5.4 DENTIN HYPERSENSITIVITY POWER TIMER Ton Toff TIP o.2w 20s (for each step) CW cw black (not activated) 0.3w 04w o.sw O.6Ww Once the sensitive area has been localized, begin treatment by applying the specific diode laser fluoride gel. The gel also contains potassium nitrate that is reactive to the diode laser wavelength (980 nm) even if it is not coloured. This is an advantage that helps operative visibility. Proceed by moving the fibre over the gel, not in contact, with five consecutive 20 second intervals at the following power settings: 0,2W - 0,3W - 0,4W ~ 0,5W ~ 0,6W. Remove the fluoride gel and repeat the procedure (from 0,2W to 0,6W) brushing the fibre in contact over the treated area. It is especially important that the brushing technique be used in order to cover all dentinal tubules. The desensitization occurs when crystallization of the saline component in the gel occurs inside the tubules, blocking them. After treatment, test the effectiveness with cold air spray. If the patient stil feels sensitivity, repeat the contact treatment. Note: if treating a vital prosthetic stump do not use a power level above 0,2 W and do not bring the fibre into contact with the surface of the tooth. After treatment use a fluoride gel on all sides of the tooth. 5.5 TM) THERAPY POWER TIMER Ton Toff TIP 0,7W 60s cw cw Biotip Lase over an area of icm? in front of the tragus, in the corresponding to the area of the condyle, that will be painful if pressed. With the same more place the biotip in contact with the inside the ear to irradiate the condyle from the other side. Treat the painful area with two cycles of 60 seconds each, on alternate days, for a total of 12-15 sessions. WARNING: do not autoclave biostimulation accessories. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 195.6 BIOSTIMULATION POWER TIMER Ton Toff TIP OW 60s cw cw Biotip Insert the biotip in the handpiece and place its extremity on the painful area or wound. Lase the area with a 60 second cycle at 0,1W, until the entire area is covered. The low energy defocalized beam is absorbed by the tissue, stimulating metabolic processes and tissue regeneration thanks to the thermal and photochemical interaction of the laser beam. No macroscopic alternations of the tissue takes place, but it relieves pain and speeds up the healing process of surgical wounds through photo-enzyme induction. The Krebs cycle speeds up determining an increase in the production of ATP and a greater frequency of cellular mitosis. WARNING: do not autoclave biostimulation accessories. 5.7 ANALGESIA LASER POWER TIMER Ton Toff TIP. 0,7W 50s CW CW Biotip The diode laser can induce temporary local analgesia because it inhibits the frequency of the firing of the peripheral nociceptors, therefore raising pain threshold Laser radiation determines the hyper-polarization of the membrane near the nerve fibres, secondary to the iso-orientation of the surface lipoproteins, that consequently selectively close the Na*/ K* canals, therefore limiting the transmission of sensitive stimuli in the radiated area. Such a temporary state of localized analgesia is of great advantage before any surgical procedure, or when the injection of anaesthetics is not necessary or before the injection in order to avoid the pain of the needle in children or before an extraction. Use the contact biostimulation accessory (biotip) for a total of 2 minutes 5.8 FLAT TOP HDP POWER TIMER Ton Toff TIP Iw 50s cw cw Flat top Handpiece lrradiate the painful area with the handpiece at a distance between 0 and 105 cm, at 1W power, for 50s, in order to obtain the 50 J/cm? fluence indicated in Prof. Benedicenti's protocol. In the presence of swelling, 15W are suggested. If the treatment is repeated daily or every other day for 20-30 days, the pain should retreat for three to six months. The Flat Top Handpiece spreads the energy of the laser evenly over a Icrr? surface. It can be used at a variable distance of up to 105 cm without modifying the irradiation energy, therefore ensuring equal therapeutic effects at the same tissue depth By eliminating the pain both the lesion and the swelling are reduced, since laser radiation increases the speed of microcirculation in the treated area, it also favours lymphatic drainage of the liquids. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 20The Flat Top handpiece was developed thanks to the kind collaboration of Prof. Alberico Benedicenti. Its main advantage is to distribute the energy evenly over the entire area, thus ensuring an equal depth and distribution of the laser beam on the treated area Ref. “Atlas of Laser Therapy, third edition’, Prof. A Benedicenti, Univ of Genoa. CAUTION: do not autoclave the flat top handpiece 5.9 PDT POWER TIMER Ton Toff TIP o2w 30s 25ys 25us black (not activated) Antimicrobial Photo Dynamic Therapy (PDT) is an alternative and non-invasive method of treating virus, bacteria and fungi, especially when resistant to conventional antibiotics PDT uses photosensitive compounds in combination with a light source of a specific wavelength. In the presence of oxygen the specific wavelength can excite the molecules and create reactive species such as singlet oxygen or hydroxyl radicals that can Kill cells. Since irradiation can only occur on tissue, PDT finds its application only on local infections. In dentistry PDT is used for the treatment of oral cancer, oral mycosis, diagnosis of precancerous oral lesions and in the treatment of periodontal disease. Irrigate the treated area with hydrogen peroxide 3%-10vol and then lase over the area Carry out at least three cycles of hydrogen peroxide followed by the laser. Repeat treatment every 7-10 days, according to tissue response. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 216. COSMETICS 6.1 SINGLE TOOTH WHITENING POWER TIMER Ton Toff TIP 2w 15s cw cw Biotip The use of Doctor Smile LWS Whitening System is recommended. It contains 30% hydrogen peroxide and is intended for specific use in combination with the diode laser. It also contains titanium dioxide that improves its efficiency and safety. Before starting, accurately clean the area. Position the dam to protect the gums and asses the shade of colour of the teeth that will be treated. Isolate the gingival margin with the photopolymerizing liquid dam, carefully drying the area with air spray. Mix the powder and the liquid contained in the package, and apply the mousse in 2-3 mm thickness of the front surface of the teeth. Begin activation with the laser, fitted with the single tooth/biotip accessory. Lase at a imm distance, for 15 seconds on each tooth, with tiny circular movements. Let the product rest then for 10 minutes Remove the mousse and repeat if necessary without rinsing (maximum two applications). Remove the dam using tweezers and rinse accurately with water. Now verify the degree of whitening obtained with the colour shade guide. Inform the patient with detailed instructions that he/she must avoid chromogenous food for the next 48 hours in order to not compromise the results. WARNING: do not autoclave whitening accessories, 6.2 WHITENING POWER TIMER Ton Toff TIP SW 30s cw cw Large Area The use of Doctor Smile LWS Whitening System is recommended. It contains 30% hydrogen peroxide and is intended for specific use in combination with the diode laser. It also contains titanium dioxide that improves its efficiency and safety. Before starting, accurately clean the area. Position the dam to protect the gums and asses the shade of colour of the teeth that will be treated. Isolate the gingival margin with the photo-polymerizing liquid dam, carefully drying the area with air spray. Mix the powder and the liquid contained in the package, and apply the mousse in 2-3 mm thickness of the front surface of the teeth. Begin activation with the laser, fitted with the large area whitening arch accessory. Lase at a Imm distance, for 30 seconds on each quadrant. Let the product rest then for 10 minutes. Remove the mousse and repeat if necessary without rinsing (maximum two. applications). Remove the dam using tweezers and rinse accurately with water. Now verify the degree of whitening obtained with the colour shade guide. Inform the patient with detailed instructions that he/she must avoid chromogenous food for the next 48 hours in order to not compromise the results. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 226.3 HAEMANGIOMA POWER TIMER Ton Toff TIP 15W - cw cw black (not activated) Usually what is commonly perceived as a haemangioma on the lip is actually a vascular lesion caused by trauma or biting. A precise anamnesis is important for correct diagnosis. Proceed by inspecting the lesion, compressing it with a glass to see if it becomes pale, and illuminating it to highlight the vessels as black and the healthy surrounding tissue as red. This protocol will selectively raise the temperature inside the lesion to 70°C; for this reason a laser analgesia treatment is recommended to reduce pain (at a 1. cm distance 2 minutes at 0,6W, CW). The treatment will induce the photo-coagulation of the lesion, thanks to the phot-thermal effect, since the wavelength of the diode laser is selectively absorbed by haemoglobin but transmitted by skin or the overlying mucosa. The operation will fully respect the surrounding tissue as required by modern minimally invasive surgery. Irradiate with the laser keeping the tip at a few millimetres of distance from the lesion, in order to coagulate the content and not the other tissues. After a few seconds the colour will change from bluish- red to greyish -white. This is a sign the treatment is proceeding well. Continue until the lesion is completely white and has decreased in volume. The patient can the be dismissed. Healing will continue spontaneously and no scarring will occur 6.4 GUM SMILE POWER TIMER Ton Toff TIP. L6w - cw cw black (activated) A Gummy Smile is characterized by an anomalous growth of gingival tissue over the upper teeth of over 3-4 mm. Patients may feel strongly conscious about it, such that they may limit their smile. Carry out a precise gingivectomy with the laser, by modelling the gingival margin with an external bevel, in order to restore the physiologic appearance of the adhering gum Usually the application of a topic anaesthetic (lidocaine spray 10%) is sufficient to limit pain during treatment. If necessary, infiltrate anaesthetic without vasoconstrictor. The gum will heal spontaneously by second intention, without sutures. 6.5 GUM DEPIGMENTATION POWER TIMER Ton Toff TIP 15W 30s 10ms 10ms black (not activated) This treatment can reduce, at times eliminate completely, the hyperpigmentation of gums. The diode laser is also sensitive to the melanin chromophore, as well as haemoglobin, for this reason it is effective in depigmentation. The aim of this treatment is to vaporize the pigmented gum tissue and operate a sort of resurfacing of the mucosa. Place the tip tangent to the gum and caress the surface to ablate the area layer by layer. Do not go beyond the vascular bed. If the pigmentation cannot be removed in one session, repeat treatment after 20 days, to remove residual pigmentation. Infiltrate anaesthetic without vasoconstrictor if the patient feels pain during treatment. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 237. CONSERVATIVE 7.1 SEALING GROOVES POWER TIMER Ton Toff TIP. 1W - 50ms 50ms black (not activated) Begin by applying the fluoride-potassium nitrate gel along the grooves. This gel is sensitive to the diode laser wavelength (even if uncoloured). The lack of colour will aid visibility during operation. The treatment aims at reducing the risk of caries on the occlusal surface by inducing laser crystallization of the saline component in the gel, so that the groove is sealed Pass the tip repeatedly, in contact, over the entire extension of the grooves filled with gel The treatment will limit the exposure to caries of areas with dentin uncovered by enamel, as often in the case of permanent molars and premolars, immediately after eruption. 7.2 CAVITY DECONTAMINATION POWER TIMER Ton Toff TIP 2,5W 10s 10ms 10ms black (not activated) Use this treatment immediately after the removal of decayed tissue to decontaminate the cavity created with a rotating instrument effectively. This will reduce the risk of future contamination by removing the bacteria from the cavity. The procedure is similar to endodontic decontamination: in this case, use the laser radiation in cycles of 10 seconds each, preceded by irrigation with hydrogen peroxide 3%-10vol Direct the laser both towards the bottom of the cavity and towards the sides, in order to not leave any surface untreated. Then proceed with normal restoration. 7.3 VITRIFICATION POWER TIMER Ton Toff TIP. 04Ww - cw cw black (not activated) In case of deep caries with minimal damage to the pulp chamber, the laser can aid in the vitrification of the bottom of the cavity, to avoid the devitalization of the tooth Place the tip in direct contact with the surface of the tooth and ‘brush’ over the entire area; continue until the desired effect is obtained i.e. a compact and smooth cavity bottom. WISER — practical guide and clinical protocols. = AMNII40.3. March 2017 24