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SINCLAIR DENTAL LASER TECHNOLOGY PROGRAM

Self-Study Guide

Pre-Certification Program KaVo KEY 3 Laser

Module

1

Reg. Number: __________________________

S I N C L A I R D E N T A L

Pre-Certification Program for the

KaVo KEY 3 Laser

www.sinclairdental.com

Sinclair Dental 2007 Attn: Laser Technology Program

900 Harbourside Drive North Vancouver, BC V7P 3T8

http://www.sinclairdental.com/

Table of Contents

Welcome & Introduction 1

Glossary of Terms 2

The World of Lasers 3

Setting Expectations 5

History of Laser Theory 6

Laser Characteristics 8

Laser Effectiveness - Absorption 10

The Most Common Dental Lasers 12

Laser Components 14

Ablation and the Importance of Water 15

The Principle of Ablation 16

KaVo KEY 3 Laser Overview 17

The Touch Screen 17

Foot Control 18

Integrated Systems 19

Feedback Mechanism 19

Safety Considerations 22

Clinical Indications – KaVo KEY 3 22

Laser Assisted Periodontal Therapy 24

Clinical Studies in Periodontal Therapy 26

The Business Side - Laser Integration 29

A Successful Recipe 30

Checklists 31

Conclusion & Wrap-Up 33

Acknowledgements 34

K A V O K E Y 3 P R E - C E R T I F I C A T I O N

1

Welcome & Introduction

The Pre-Certification Process –Instructions

elcome to the world of Laser Dentistry! You are about to embark an exciting learning curve as we introduce you to the theoretical background and concepts associated with Laser Dentistry in general – but more

importantly – as we step you through the benefits and features of the KaVo KEY 3 laser which your office has invested in.

This purpose of this self-study program is to prepare you for KaVo KEY 3 certification which will be offered to you in the coming weeks. Given the certification program is an intensive one-day learning experience, Sinclair Dental has developed this Pre-Certification Program to ensure all participants arrive on the day of Certification with common baseline knowledge.

Your Pre-Certification Program consists of four parts:

The pre-certification self-study guide

Registration Form

Self-Addressed Envelope; and

Self-Study Examination

You will notice that the self-study guide, the registration form and the examination are all numbered. Because the completion of this course is required as part of the certification process for any practitioner using the KaVo KEY 3 laser, Sinclair Dental will maintain records of successful completion and will provide you with confirmation of this continuing education module once the examination is received and you have successfully passed the program. Please note that it is important that you finish this program on your own and that you return the numbered examination and registration form that has been assigned to you.

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We would anticipate that to read the self-study guide and to write the examination will take a maximum of three to four hours. You are encouraged to complete the program as quickly as possible and to then send your completed exam by mail to ensure your results are received prior to the scheduling of your certification day.

Please keep in mind that if this is your first exposure to lasers, the concepts fall outside of what would be considered traditional clinical practice in dentistry. Do not despair if on first reading this information that you find yourself a little lost. In time, the basics will become commonplace – trust us! You are encouraged to take notes and to raise any questions along the way that you may have with your instructor on certification day. Remember: you will have plenty of support from your certification instructor in addition to the support of your Sinclair Dental team in addition to other online resources. The intention of this pre-certification program is just to cover the basics and to get you thinking about the technology.

Before we get started, here is some basic terminology that you may wish to review.

Glossary of Terms

There are a number of terms which will be used repeatedly in this document. Here is a quick reference list for a few of the most important terms.

Ablation: Is the process of cutting and removing tissue.

Absorption: Is used in reference to the laser’s energy being taken in by specific oral tissues

Frequency: Refers to how fast the laser will fire repetitively within a given time

Level of Excitation: A pre-set threshold at which energy is released as a laser beam

Universal Laser: Is a laser that can be used on both hard and soft tissue

Wavelength: Distance between successive crests of a wave

Paradigm: A way of thinking or a way of doing things.

R E M E M B E R

T H I S I S J U S T

T H E F I R S T

S T E P I N Y O U R

L E A R N I N G –

S O D O N O T

D E S P A I R I F

I T T A K E S

S O M E T I M E

F O R Y O U T O

G R A S P A L L

C O N C E P T S


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The World of Lasers

Embracing the Paradigm Shift and Setting Your Expectations

any dental practitioners ponder whether to incorporate dental lasers into practice and whether the benefits will outweigh the considerable investment. Well, we all know that dentistry is changing. We also know that our patients

are more and more educated on what treatment options are available to them with the proliferation of the Internet and other resources which are more widely available. Many of us have likely experienced patients asking about technology they have heard about, or have had to field questions when they ask about your office taking the next step in adopting more “advanced” technology. They generally want to know when we will be able to make things faster, easier and less painful. The bottom line is that our patients’ expectations are increasing with each year that passes as they have come to expect that dentistry will offer the same kinds of technological advances they see in other disciplines of healthcare. So while routine dentistry remains alive and well, we have to ask ourselves if it is time that we, as dental professionals, step up to the technological plate.

The introduction of dental lasers provides practitioners with one more tool in being able to offer exceptional dentistry. When integrated most effectively, laser technology will afford you the opportunity to bring certain aspects of your practice to the next level as well as to provide your patients with some of the latest procedures available today. So whatever your personal motivator for embracing laser technology, the cornerstone of our adoption of this technology should be patient care and comfort

There is an old saying that reads, “You don’t know what you don’t know”. And as logic dictates, if you don’t know, then you’ll always do what you’ve always done. Certainly this isn’t a profound thought when you get right down to it, but it is very easy for any practitioner to get into a rut and to deliver the same services in the same way, year after year, to his or her patients. We all hear a lot about clinical boredom or dental burnout

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You Don’t

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as being a leading cause for practitioners leaving practice or in simply becoming disenchanted by our profession. Embracing new ways of doing things and shaking things up a little can help to alleviate that boredom. So in promoting the concept of change, it will be important to challenge yourself to be accepting of a new way of doing things. For those of you who have never used a laser, you will quickly come to see how you will need to adopt ways of doing procedures differently as you rely on your other senses of sight, smell and sound.

This new way of doing things and embracing change is called a paradigm shift. Think of a paradigm shift as a change from one way of thought to another. It’s an evolution of sorts – and it will likely come to some of you a little easier than to others. With this said, it is time to learn about and embrace laser technology.

In all likelihood, the adoption of lasers into your practice is going to change the way you practice dentistry and will transform your dental hygiene practice. Moreover, it will change how your practice is perceived by your patients, and how you will begin to look at traditional methods of treatment. Of course, as you begin to embrace the paradigm shift and begin to adopt the laser as part of your standard practice, it will simply become more a part of your day-to-day comfort zone and you will be able to more confidently prescribe laser assisted therapy. The first hurdle for most dental professionals to overcome is to understand that change can be fun! So while we may begin to tackle things differently than we have done in the past, with the completion of this pre-certification module – and then your certification – you will find yourself with the knowledge to begin the integration of laser technology within your own practice. It is important to remember that regardless of your role on the dental team, everyone

will play an integral role in the successful integration of this technology.

The fact is, lasers are everywhere – and to some extent it becomes our responsibility to keep up with the changing world understanding the outside influences on dentistry and dental hygiene. Just think about how many advertisements you see for laser hair removal and laser eye surgery. We have laser scanners at the grocery store and there are lasers in our DVD and CD players as well. Of course, lasers in dentistry are not new – but we have seen them more widely used over the last decade for various applications.

Everyone enters into this pre-certification module from a different vantage point. Many of you likely had little to no training on laser technology in dental school or dental hygiene school. Perhaps you have already had some exposure to lasers from continuing education courses or as a result of purchasing another kind of laser for your practice. For others of you, this may well be your first introduction to lasers. Whatever your background, the goal here is to provide you with the knowledge of what kinds of dental lasers are out there in the market, to specifically highlight the features that make the KaVo KEY 3 laser unique – and ultimately provide you with the knowledge on how to offer your patients a non-surgical approach to treat certain problems.


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Setting Expectations

For the vast majority, the introduction to new technology can be approached with a certain amount of trepidation and skepticism. Understandably, when it comes to laser technology, certain expectations of the equipment are important. You need to ask yourself if your expectations are based on knowledge, based on what you have read, if they are based on what others have told you or perhaps are based on what you assume to be correct. Are your expectations of the laser realistic? What do you want the laser to do? Do you know what the laser can do? What it can’t?

As you approach your education you will find that a universal laser like the KaVo KEY 3, will provide you with the following:

The ability to perform multiple procedures. This is a very practical matter such that dentists and dental hygienists can turn to one device – are able to reach the controls and instruments easily and efficiently – and can use that single laser to effectively perform many known dental laser procedures.

The opportunity to improve patient comfort. It can have the ability to change a patient’s perception of dentistry and your practice overall. This may be accomplished by offering some restorative procedures without anesthesia or in being able to do non-surgical periodontal procedures, as an example.

It can improve the financial performance of your practice. This can take the form of increased productivity, of attracting more patients because of the technology, or in being able to perform procedures that may have otherwise been referred out – ultimately generating new revenue for the practice.

In the end, laser technology should be an ideal “win-win” scenario for everyone. It should benefit the patient, the practice, the dentist, and the hygienist.

With these three expectations in mind, we can now explore some basic laser physics in an effort to show you how one kind of laser differs from other. As you come to understand a brief history of lasers, you will better understand which laser is best for use in various dental applications. Remember that education is the key for the adoption of new technology.


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History of Laser Theory

Back to the Basics of How Lasers Work and What Makes Them Different

lthough the first working laser was demonstrated back in 1960, lasers have since become a multi-billion dollar industry affecting many facets of industry from healthcare and beauty through to hi-technology, data processing and

entertainment. Interestingly though, laser theory itself dates back to the early 1900s by two men named Neils Bohr and Albert Einstein. Now for the purposes of this dental laser program, we need not delve into the details of quantum mechanics, but we do need to understand some basic physics in a very simplified manner.

Neils Bohr postulated the Quantum Theory of Light. This theory is founded on a unit of light called a photon. Bohr stated that the photon is the building block of light. In this respect, a photon is to light, just as an amino acid is to a protein, or a brick is to a building. Albert Einstein then went on to theorize that there were two types of light emissions. The first kind of light is called spontaneous emission while the second kind of light is called stimulated emission.

Spontaneous Emission is the kind of light we get from a light bulb when electrical energy is conducted through a filament and photons are dispersed at different wavelengths;

Stimulated Emission theorizes that a substance could be stimulated to emit identical photons. It is these identical photons which are the key to how lasers work.

The term “laser” is actually an acronym that stands for:

L ight

A mplification by

S timulated

E mission of

R adiation

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Laser light, all types of visual light discernable by the eye, and all forms of radiation are what we call electromagnetic radiation. All types of electromagnetic radiation move in the form of electromagnetic waves. A wave is defined by a specific wavelength and frequency of oscillation. It is the wavelength that defines the different types of lasers on the market today and this is measured in nanometers (nm).

Laser light has three primary characteristics:

1. Monochromatic: this means that all of the light has the same wavelength and therefore the same color;

2. Collimation: this means that the light does not diverge or converge and

therefore is collimated (or dispersed) as a beam;

3. Coherence: this means that the photons produced by the light emission move in exactly the same pattern, just like waves on the water.

All kinds of light falls somewhere within the electromagnetic spectrum as you can see in the diagram on the next page. The light in the middle of the spectrum is what we call visible light. This is the light, at varying wavelengths which are visible – and safe – to the human eye and is what allows us to see different colors of the spectrum. Wavelengths in the visible light spectrum range between 400 to750 nanometers. The light to the left of this spectrum is what is called invisible ionizing radiation – while the light to the right of it is called invisible thermal radiation.

Invisible Ionizing Radiation is the electromagnetic radiation that includes x-rays and ultra-violet (UV) light. This form of electromagnetic radiation can be dangerous because the wavelengths are short enough to penetrate the cell membrane and damage DNA – and are thus potentially cancer causing.

Laser

Laser Coherence

The light travels uniformly as a beam

Collimation

The distance between waves is identical


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Invisible Thermal Radiation is the electromagnetic radiation which has longer wavelengths making it unable to damage the DNA, and therefore safe for patients. Nearly all dental lasers, including the KaVo KEY 3 laser, fall within this side of the spectrum and are non-ionizing, non-cancer causing and non-mutagenic.

Laser Characteristics

Now that we have discussed a brief history on laser theory and some generalities of the scientific differences between one type of radiation over another, we can now delve into the characteristics of lasers which will help us to better understand their specific applications in dentistry.

In your reading through dental or hygiene journals, discussions with colleagues or through your attendance at various courses, you will likely come in contact with different lasers with different descriptions. This can be a little confusing at first until you begin to understand that there are different kinds of dental lasers, each with varying applications. The most common descriptors you will come to hear, however, will either be the brand name of the laser, or the active medium of the laser. We will go into more detail on active medium in a moment, but for the time being it is important to note there are five main types of lasers in dentistry.


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These five types of lasers are:

1. Argon

2. Diode (810 or 980 nm)

3. CO2

4. Nd-Yag

5. Erbium (Er-Yag or Er-CR-YSGG)

What makes each of these lasers unique is the active medium. Each variety of laser has a specific active medium which, when stimulated by an energy source, will produce a specific type of laser light. So materials such as argon, carbon dioxide or other manmade substances such as erbium crystals all serve as a medium – thorough which energy is passed – ultimately producing a specific wavelength.

Put simply then, there are three ways to describe a laser:

Brand Name

This simply refers to the manufacturer or the trade name of a particular laser. As examples, the KaVo KEY 3 laser, the Odyssey® Laser, BioLase®, or the LVILase®, etc.

Active Medium

This active medium is usually either a manmade crystal or a form of gas. Examples of these active mediums include Er-Yag crystal (such as for the KaVo KEY 3 laser), a Diode crystal (used in the Odyssey® and LVILase®), or CO2 gas used for surgical lasers (which are less common) or a ER-CR-YSGG crystal (which is BioLase®)

Wavelength

As we have already discussed, laser light can be found in varying wavelengths. Examples of this would be 2940nm (KaVo KEY 3), 810nm or 980nm (diode lasers vary in wavelength), 2780nm (BioLase®). So while it is less common to hear a practitioner refer to the wavelength specifically – it can be done.

So now that you know that lasers can be described by their brand name, active medium and their wavelength, we need to further investigate what implications wavelength has on human tissue.


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Laser Effectiveness - Absorption

It is important to understand that each tissue in the oral cavity is attracted to specific wavelengths. Conversely, individual wavelengths are absorbed by certain tissues. For example, water is absorbed by longer wavelengths such as the KaVo laser at 2940 nm, but it is not absorbed by a diode laser which has a short wavelength of only 980 nm. Alternatively, hemoglobin (blood) is absorbed by a short diode wavelength, but is not absorbed by the longer KaVo wavelength. In this respect, each laser will react differently with the tissues – and thus present a different result.

It is for these reasons that some lasers are better for curing (those that are highly absorbed by camphorquinone), other lasers are best for use with soft tissue – while others work best for hard tissue. As you begin to piece together the basic principles of physics and laser light generation, you will begin to see that different types of lasers ultimately have different applications in dentistry. Put simply, you need to understand that one kind of laser is not the same as another kind of laser. It is not uncommon for clinicians to believe that one kind of laser is the same as another – which can ultimately cause harm in patients if it is utilized incorrectly. With this in mind we need to be educated as to what tissue in the oral cavity our particular kind of laser is attracted to in order to avoid causing damage to certain tissue.

So when we boil all this information down, what lies at the heart of everything is absorption. Irrespective of what kind of laser we are referring to, the fundamental message is that human tissues will absorb or attract different wavelengths. When the energy of the laser wavelength is absorbed by the tissue, it will affect the tissue and therefore we get our resulting effect.

You will see in the picture diagram to the right, that laser light interacts with tissue in three different ways. The laser light may be reflected off of the surface, which would happen with amalgam fillings. The laser light may be transmitted or scattered deep into the tissue. Finally, the laser light may be absorbed by the tissue. The desired outcome is to have the laser absorbed by the tissue. Transmission or scattering of the laser energy deeper into the tissue can cause detrimental effects to the surrounding tissue, which is what we want to avoid.

Reflection

Transmission or Scattering

Absorption


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So when you are choosing a laser for your practice there are several things to consider:

1. What do you want the laser to do? (E.g. control bleeding, periodontal

therapy, crown lengthening, hard tissue preparations, etc.)

2. Is the wavelength of your laser attracted to the tissue for the procedures

you want to do? (E.g. is it attracted to hemoglobin or water?)

3. Will cutting (or ablation) of the tissue be possible at the lowest

temperature possible given that we know higher temperatures can cause

damage?

4. Does the laser offer multiple applications? (E.g. is it suitable for hard and

soft tissue, or is it just for soft tissue?)

5. What is the cost versus benefit of the laser and what are the ongoing

costs to my practice?

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T H E M A I N

D I F F E R E N C E

F R O M O N E

K I N D O F

D E N T A L

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The Most Common Dental

Lasers

A review of Dental Lasers and Their Basic Applications

n Chapter 3, we touched upon the fact there are five common types of dental lasers. Now that you better understand the implications of wavelengths and their effects on tissue, we will take closer look at each of the most common dental

lasers available on the market today.

1. Argon Laser

The Argon laser typically produces a wavelength of 488 nanometers (nm)

This is the peak wavelength for the polymerization of composite resins and therefore they are most often used for high intensity curing.

The Argon laser is highly absorbed by red pigmented structures and is poorly absorbed by water.

2. Diode Laser

The diode laser has a wave length of either 810 or 980nm.

This is perhaps the most common dental laser on the market today. These lasers are ideal for soft tissue procedures since the wavelength is well absorbed by hemoglobin.

Care must be taken with a diode laser as they do generate considerable heat. This heat can sometimes cause necrosis of the tissue because of a charring effect. More care must be taken since the penetration of the laser beam may

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cause deeper thermal damage that may not be immediately apparent. That being said, the diode laser does provide excellent homeostasis.

Diode lasers cannot be used for hard tissue cutting nor are they suitable for periodontal procedures such as curettage. This is mainly due to the scattering and transmission of the laser energy deeper into the tissue than what we require.

3. Nd-YAG Laser ( Neodynium Yttruim Aluminum Garnet)

The Nd-YAG laser produces a wave length of 1064 nanometers.

This laser must be pulsed in its delivery, as the Nd-YAG wavelength can penetrate quite deep into the dental soft tissue.

The ND-YAG laser is not used for cutting hard tissue.

Primarily used for soft tissue surgical procedures, although its wavelength is poorly absorbed in both water and hemoglobin

4. CO2 Laser (carbon dioxide)

The CO2 laser has a wave length of 10, 600nm.

Because of its absorption characteristics, this high wavelength cuts very quickly on the surface level.

It is mainly used for soft tissue surgery; however, it will ablate the tissue very rapidly

We find that fewer and fewer CO2 lasers are commonplace in the dental practice. They can cause charring of the tissue and therefore are not designed for periodontal procedures because of the heat they produce

This laser is not indicated for hard tissue ablation

5. Er-Yag laser (Erbium Yttrium Aluminum Garnet)

The wavelength of the Er-YAG laser is 2940nm.

It is very highly absorbed in water which makes this lasers system useful for caries removal and cavity preparations.


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Energy Pump - origin

Active medium

Mirrors

Laser cavity

Highly reflective Partially reflective

It is ideal for soft tissue procedures whether that be surgical or periodontal curettage, as the laser ablates the tissue very rapidly on the surface level.

The energy of the laser does not extend deeper down into tissue and therefore it provides a high degree of precision and safety for the different procedures.

As already discussed, this particular wavelength is not absorbed by hemoglobin – but rather by water.

Laser Components

The physical components within a laser, regardless of the active medium, are set up in a similar manner. The inner workings of the laser are housed within a laser cavity – and within that cavity is the specific active medium.

In the case of the KaVo KEY 3 laser, the active medium is the Er-YAG (or Erbium Yttrium Aluminum Garnet) crystal. On top of the active medium is the pump origin. This is an energy source which will stimulate the active medium. In the KaVo laser, the pump origin is a flash lamp (which looks very similar to a strobe light for those of you who remember the 1970s). When the active medium is stimulated by the energy source, the photons within the medium are activated and begin to bounce back and forth within the laser cavity. On either side of the laser cavity, you will notice that there are two mirrors. The mirror at the back of the laser cavity is highly reflective, while the mirror at the front of the laser cavity is only partially reflective. When the energy of the photons bouncing back and forth between the two mirrors reaches the appropriate level of excitation – these photons are able to pass through the partially reflected mirror. At this point the energy exits the laser cavity as the laser beam of light. When the laser light hits the target tissue, we will again have one of three consequences occur. The laser light will be reflected by the surface, it will be transmitted or scattered

deeper into the tissues, or it will be absorbed by the tissue.


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Ablation and the Importance of Water

So let us once again recap a few key points as we continue on our journey in better understanding dental lasers:

We know that active mediums make the various lasers on the market different from one another and that they each have specific applications in dentistry

Depending on the wavelength of the laser, the energy is absorbed differently by tissues in the mouth

We know that it is the absorption of the laser energy that is key to obtaining the desired result

Given our desire to keep temperatures low and tissue charring to a minimum, we have found that using a laser that is attracted to water will minimize possible side-effects

Water absorbs the Er YAG wavelengths (because they are longer wavelengths) – but it does not as readily absorb shorter wavelengths. Shorter wavelengths found in the Argon, Diode and Nd YAG lasers have a high degree of transmission through water (but not absorbed by it)

So let us ask ourselves a quick, but important question. What is the one substance

that is present in all human tissue? The answer, of course is water!

Hopefully by now you are starting to piece together all of this information and are beginning to see the versatility provided in an Er YAG laser by virtue of the attraction to water. We know that water comprises enamel, dentine, cementum, bone and soft tissue in varying percentages (see figure). Knowing there is water in each target tissue, we will be effective in performing a variety of different procedures.

P E R C E N T A G E

W A T E R

Enamel – 3%

Dentine – 12 %

Cementum – 12%

Bone – 25%

Soft Tissue – 75%


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You will notice in the graph above as well, that the Er-YAG laser, with a wave length of 2940nm, has the highest absorption of water when compared with all of the other available dental lasers on the market today. This is why the KaVo KEY 3 laser affords such versatility in practice.

The Principle of Ablation

So what exactly does ablation mean? And how does ablation work? Well, the answer to that is quite simple. Ablation is just another word for cutting or removal of

tissue. When the lasers energy is absorbed by the water molecules, it causes them to vibrate. This vibration increases the pressure of the water inside of the tissue. The resulting effect is a series of tiny micro explosions of water molecules which causes the tissue to ablate. These thermo mechanical ablations or micro explosions of the water occur within both the hard and soft tissues. The wavelength of 2940nm (Er-YAG) is absorbed by the water molecules within the tissue and not by the tissue itself. Therefore, ablation occurs without the dissipation of heat. This is extremely important to remember!


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KaVo KEY 3 Laser

Overview

Understanding the Components of the KaVo KEY 3 Laser

ell we have spent a good deal of time in preparing for this point, but now that you have the background on the fundamentals of dental lasers, we can focus more on the specifics of the KaVo KEY 3 laser. If you have the laser

in your office, you are encouraged to turn it on and to examine the various components while you are doing this pre-certification training.

The Touch Screen

First of all, if you look at the touch display on the front of the laser, you will notice that this is a user friendly computer screen. All of the buttons are activated by a light touch with your fingertip or the tip of your nail. On the left hand side of the screen you will see all of the programs listed. You will also notice that along with each program, the laser will tell you which hand piece should be used. On the right of the screen, you are able to locate which program you would like by either pressing the up or down arrows – or alternatively pressing the page up or page down button – just as you would on a computer.

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There are 24 pre-set programs for common dental procedures programmed in the laser. Once the desired program has been selected, you press OK at the bottom of the screen. The energy value for the desired program is presented in the middle of the screen in millijoules – while the frequency value is presented in hertz. This portion of the screen also shows the momentary and peak values which are the threshold values already set into the computer by the manufacturer. On the right of the screen are the Detect and Feedback buttons. Currently these two buttons are only used for the periodontal programs. On the bottom right is the Calibration button -- which is used to calibrate the 2062 hand piece, again for periodontal curettage.

The middle button on the bottom row will allow you to turn on or off either the air or the water. The last button on the bottom left is the Ready button. Please note that both the energy and frequency can be altered according to the situation that presents itself to you. Most times, however, the pre-set values that are in the computer programmed by the manufacturer are appropriate.

Foot Control

The foot control also has a variety of control availability on it. The top ring on the foot control has no function other than to assist you in moving the foot pedal by tucking the tip of your foot under the ring and lifting it. All of the important settings and parameters that are found on the display screen may be easily changed with the foot control, without having to lay your hand instrument down. The button on the right side of the foot pedal is the ready button. The button in the middle of the foot control allows you to adjust


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the energy and frequency of the program. The button on the left of the control allows you to control the water spray settings. Finally, the large button at the base of the foot control is the Activation button. When doing laser-assisted periodontal curettage, this bottom button is also used to reset the peak display during the calibration process (calibration of the laser is covered during the certification training).

Integrated Systems

At the back of the laser, there is a small door which provides access the integrated water reservoir. It is important to only use distilled or de-mineralized water in the KaVo laser. When you are running low of water, a message will show on the display screen prompting you to re-fill the bottle. The KaVo laser also has an integrated compressor and cooling system built in to the chassis so it does not require an external air/water connection. The laser does, however, require a dedicated electrical

circuit in each operatory where it will be used.

On the front of the laser, below the display screen, you should have a small round magnet with a number on it. This is the calibration stone which is used to calibrate your particular laser. ALWAYS keep this calibration stone attached to the front of the laser. Once it is removed for the purposes of calibration, then it should be immediately be replaced on the laser. The laser will not work without it and that particular calibration stone is designed to work with your particular laser only and it is a very costly repair should it get lost.

Feedback Mechanism

The feature that makes the KaVo KEY 3 laser unique in the marketplace is that it is currently the only laser which incorporates a feedback mechanism into the programming. The feedback technology is an internal process within the laser which provides added safety and precision to our procedures. Currently the Feedback Mechanism is designed for use only with the 2061 hand piece and it is currently only activated during periodontal procedures. Let’s take a moment to discuss what the feedback mechanism is, and how it works.


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The feedback mechanism works through excitation of fluorescence of various target tissues. While this sounds quite technical, all you need to be aware of is that all tissues in the oral cavity have a specific fluorescence to them naturally. These fluorescence values have been programmed into the laser computer. What makes the KaVo KEY 3 laser unique from other lasers then is that it actually has two lasers built into the machine. First, there is an internal diode laser. It is a 655nm laser and is used by sending out a “search” signal through the 2061 periodontal hand piece and out the end of the sapphire chisel tip. This is a detecting laser beam as opposed to an actual working beam. In the periodontal application, it will detect whether or not tartar is present on the root surface.

You will notice on the next diagram that when the diode laser sends out its signal, it travels through a series of lenses before it exits the tip of the hand piece. During this process, the diode laser is searching for any potential tartar by detecting its fluorescence values. Calculus and tartar have a different fluorescence value from cementum. Because of this, the laser is able to easily differentiate between what is tartar, and what is cementum and will only fire when it detects tartar. This helps indiscriminate removal of cementum.

FEEDBACK MECHANISM: THE EXCITATION OF FLOURESENCE


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When the activation button on the foot pedal is pressed, the feedback system begins to work. The initial diode laser sends a signal through the 2061 hand piece and down into the periodontal pocket. As the diode laser encounters substances within the pocket, it will then send a signal back up through the hand piece and through two filters. The first is an optical filter, and the second is an electronic filter. These two filters modulate the information and it is then compared to the fluorescence values programmed into the laser. If the fluorescence value is greater than the threshold value that is already programmed, the laser will fire. The internal energy source will activate the Er-YAG crystal, and the laser beam will be sent down through the hand piece to subsequently remove the tartar. This whole process happens instantaneously.

If, however, the signal coming back from the periodontal pocket, goes through the filters, and the value is lower than the programmed threshold, the laser will not fire. So in this respect, it is as if the laser is on the search and destroy mission. If it detects tartar, it will fire and remove it. If it does not detect tartar, it will not fire. Because the laser is able to detect the difference between cementum, the root surface, and calculus – it makes for a very selective removal system.

As you may already know, we have learned over the years that the process of completely removing the cementum from the root surface is no longer considered ideal practice. We used to believe that scaling and root planning with a resulting hard glossy root surface, was the ideal situation for gingival re-attachment. We now know that if the layer of cementum remains on the root surface, we will have a much greater chance of gingival re-attachment within the periodontal pocket. Our goal then

THE DETECTION AND FIRING

PROCESS


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obviously is to clean the root surface of all tartar, but to leave the cementum intact. This is the only laser on the market that allows this to be done. It is therefore, the safest laser for periodontal curettage and provides an excellent value-added service to offer our patients.

Safety Considerations

So you may be wondering if the Feedback Mechanism is in place, could the laser still cause damage to the tissue and to the patient? The answer is YES! Just as we can cause damage with our scalers and ultrasonic instruments when not used properly, we too can cause damage with a laser. But do we cause damage when we see our patients for routine maintenance? The answer is no because we have been trained properly on how to use our instruments.

The next question should be then, is it possible to use the laser and not cause any damage? The answer here is absolutely yes! With proper training and a thorough understanding of the technology, this tool will allow you to offer amazing treatment options to your patients and not have to worry about negative repercussions.

We simply need to remember to treat the technology with respect. It is a sensitive and expensive piece of advanced dental equipment that you will come to better understand as you pursue the next level of certification.

Clinical Indications – KaVo KEY 3

Clinical indications of the KaVo KEY 3 laser include:

Periodontal applications

Implant therapy (periimplantitis)

Conservative Restorative therapy (with or without anesthesia)

Endodontics

Surgery

There are three different hand pieces that accompany the KaVo laser. While we will explore the uses of each hand piece in more detail during certification, it is important that you have a basic understanding of each hand piece.

The 2060 hand piece is designed primarily for hard substance removal.

Conservative Restorative therapy

Bactericidal effect


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Sealants

Surgical application (hard and soft)

Desensitization of exposed root surfaces

Treatment of herpes (early stage)

Treatment of apthous ulcer or canker sores ( early stages)

The 2061 hand piece is designed primarily for periodontal purposes.

Closed flap curettage

Open flap curettage

Closed flap Crown Lengthening

Implantology

Surgery

The 2062 hand piece is designed primarily for endodontics, surgery and periodontal uses.

Minor Restorative therapy

Endodontics

Implantology

Surgery

Periodontal procedures

Bacterial Reduction

As you continue through your certification process and garner clinical experience with the KaVo laser, you will come to find that each of these hand pieces can be interchanged for different procedures. This means that although a hand piece may have been originally designed for a specific purpose, you may find that in your hands it will be quite appropriate for something entirely different. The flexibility allows the operator a great degree of imagination in providing the best service for that particular situation.

2 0 6 0 H A N D

P I E C E

2 0 6 1 H A N D

P I E C E

2 0 6 2 H A N D

P I E C E


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Laser Assisted

Periodontal Therapy

Implementing the KaVo KEY 3 Laser in Your Hygiene Practice

o from our reading this far, let us once again take a moment to review why the KaVo KEY 3 laser is an excellent tool for periodontal therapy:

The on-board Feedback System ensures the laser only fires upon

detection of sub-gingival tartar;

The Erbium-Yag laser, with a wavelength of 2940nm is attracted to water

versus hemoglobin. We know this is important because all hard and soft

oral tissue is comprised of varying amounts of water;

Granulation tissue is comprised of water and therefore is easily removed;

This laser is pulsed versus non pulsed in its delivery, meaning that it is

not continuously firing indiscriminately, unlike many other lasers;

There is minimal heat produced within the tissues thus decreasing the

sensitivity for our patients, allowing for many procedures to be done

without local anesthetic and minimizing potential thermal damage to the

tissue;

Results show us that we have the ability to treat many periodontal cases

non-surgically; and

For our patient, it may offer a less expensive and less invasive procedure

over surgical intervention.

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As a dental health professional, embracing the paradigm shift of technology acceptance is really determined by two factors:

Our Level of confidence in utilizing the technology; and

Our ability to communicate the benefits of the technology to our patients.

As you have come to understand, there is a considerable amount of information to process regarding laser technology. So as you take the next steps in certification and get more hands-on experience with the KaVo laser, you will come to appreciate just how important it is to communicate the benefits and value of this technology to your patients. Generally speaking, case acceptance on the part of our patients is determined by two factors:

Ownership of the problem or disease; and

Our belief in what we are saying and in our own ability to communicate

value of prescribed treatment.

When you begin to introduce your clients to Laser Assisted Periodontal Therapy

(LAPT), you need to develop internal protocols for best practices within your hygiene department. Keep in mind that you now have another treatment option available for presentation, so it is paramount that you take the time to outline the benefits of laser therapy as a non-surgical approach to your patient’s periodontal problems versus the traditional alternative of recommending surgical intervention. We can too often revert back to old habits or rely on our past knowledge, so as a team, you should consider the development of a documented set of procedures that work for you all to ensure you are offering your patients a consistent standard of care with the introduction of this technology.

By introducing LAPT into your practice, you have taken the next step to offering your patients best practice therapies. When incorporating lasers, dental hygiene treatment

planning needs to include the following:

Comprehensive client assessment

Defining treatment goals with your patient

Treatment Planning to include traditional scaling and root planning and

then assessment for possible LAPT

Performing LAPT on intra-oral sites, as needed

Additional adjunctive therapy (as necessary) to include Periostat® and/or

Atridox®

Appropriate maintenance interval to sustain health


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Re-evaluate and re-treat with LAPT, as necessary

Referral to a specialist if condition does not respond or worsens

Once again, keep in mind that the certification program will go into the step-by-step procedural details in using the KaVo laser on your patient. For the moment, simply understand that it represents an alternative therapy that you may not have been able to recommend in the past.

Clinical Studies in Periodontal Therapy

Over the years, a number of studies have been conducted comparing the KaVo KEY 3 laser with both traditional scaling and root planning as well as to other dental lasers. The lasers most often compared to the Er-YAG laser in clinical studies include the diode laser and the CO2 laser. The results of these studies have been published in such notable journals as the Journal of Periodontology, the Journal of Clinical Periodontology and the Journal of the American Dental Association, to name a few.

Of particular interest is a study published by Eberhard, Jepsen et al in the Journal of Clinical Periodontology (2003) which showed the efficacy of sub-gingival calculus removal with an Er-YAG laser, compared to mechanical debridement as in scaling and root planning. The results are shown in the photograph below. You will notice that on the left hand side of the dissected root that traditional scaling and root planning has completely removed the cementum layer of the root surface. Whereas on the right side, the Er-YAG removed the calculus but left the cementum surface intact. Studies have shown that greater re-attachment occurs when cementum remains on the root surface.


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As mentioned previously, the Er-YAG laser is attracted to water molecules. The laser’s energy is absorbed by the water and not by the tissue – resulting in a decreased heat production within the tissue itself. In vitro studies comparing CO2 lasers and diode lasers from 1997 to 2002 shows root surfaces demonstrating charring, cratering, surface cracking and carbonization (Israel, Cobb – Journal of Clinical Periodontology 1997).

Scanning Electron Microscopy in the photo above, demonstrates the cratering

and cracking of the root surface when excessive heat damages the tooth

surface.

One final study from 2000 (Aoki) from the Journal of Periodontology was an in vitro evaluation of Er-Yag laser scaling of sub-gingival calculus in comparison to ultra sonic scaling. The Er-YAG laser was reported to be the most promising laser for periodontal treatment. It had excellent ability to efficiently ablate dental calculus without producing thermal side effects.

For the purposes of this pre-certification program, we only need to touch upon the history of scientific studies at a high level. Rest assured there is nearly twenty years of research from various European and American academics pertaining to the Er-YAG laser and the benefits in clinical practice. Knowing this, it provides you with the understanding that you can begin to implement the technology within your own practice and ultimately see the results for yourself. Understanding there is a learning


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curve in truly being comfortable with this technology; the real benefit comes when you begin to see the results from LAPT with your own patients.

So as you begin to embrace the paradigm shift from a periodontal background, it is good for you to be thinking about which of your patients you could begin to treat. Think about those situations you have been trying to address year-after-year without success – and situations where you have been looking for an alternative. While you may not wish to start out on the most difficult of patients, you likely have those relationships which are long-standing and can think of some appropriate candidates to treat with LAPT.

The picture above shows how the 2061 hand piece can efficiently remove tartar

from the root surface using one of the sapphire chisels on the KaVo KEY 3 laser.


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The Business Side - Laser

Integration

Putting the Basics in Place to Ensure a Smooth Introduction of your KEY 3

o we have established that lasers in dentistry are not a new concept. Studies for the KaVo laser in particular date back to the 1980s, so we have a good deal of scientific backing in having made our decision to invest in the technology. What

is new for many of us, however, is the ability to use one laser for multiple procedures in both hard and soft tissue. For offices already making use of lasers, it will be important to educate your patients on how the KaVo KEY3 laser differs from the other kinds of lasers you may be using. For offices which have never utilized lasers in the past, you now have the opportunity to introduce the benefits of this technology.

To now, we have obviously spent a good deal of time focusing on the clinical side of laser implementation. What is important to remember, however, is that the successful integration of any new technology into practice requires the input and appropriate level of involvement for each and every team member. From the dentist to assistant and from hygienist to front desk – everyone plays a role. The ultimate goal, of course, is that we are able to speak to this technology in an informed manner in order to educate our patients accordingly.

Perhaps one of the most important aspects of integrating a laser successfully into your practice is in communicating value to your patients. Now there is no set strategy on how to do this, but the foundation begins with setting a plan on how you wish to discuss the benefits of lasers with your patients, and in turn, creating a set of protocols so each of you knows you are speaking in consistent language and ultimately prescribing it appropriately as well. Keep in mind that our patients have seen and heard a good deal about “lasers” from various media reports and movies, so it is entirely likely that you will need to correct any misconceptions they may have about the technology.

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“Wow! So

Is This Like

a Star Wars

Laser? “

“No – sorry

– it just

isn’t that

powerful!”


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Value is created by informing our patients in a concise and consistent manner, what laser technology can do for them. So whether you are informing a parent that we can now prepare a tooth in their child without the need for anesthesia – or perhaps letting a long-term periodontal patient know that we now have an alternative to open-flap surgery at a specialist’s office – patients are often eager to hear about technological advancements. At the end of the day, technology impresses the vast number of our clientele. We just need to be sure that we set the appropriate expectations.

What makes the KaVo KEY 3 laser integration somewhat unique from other technology is that it may expand treatment options within your practice. A practitioner, who once may have steered clear of surgery, may now be more open to tackling these procedures. Patients presenting with ongoing periodontal problems may now have a less invasive option available to them. Whatever the scenario, it is likely that there are a host of tangible and intangible benefits that will become evident to you as your familiarity with the diversity of this tool becomes more part of your vernacular. So while our patient care and comfort is always at the cornerstone of our decision-making, we can also improve our business in many ways as well. Some of these high-level considerations are as follows:

Exploring procedures within practice that we may have once referred out

– resulting in boosted practice revenue production

Eliminating the need for anesthesia for certain restorative appointments –

increasing patient comfort and making “routine” restorative appointments

shorter and more productive as a result

Creating referrals from existing patients impressed with the technology

and the results they see

Generating excitement in our patients resulting from the progress of their

periodontal health following laser therapy so they can ultimately share

that success with family and friends

As you continue on with the next phase of training in gaining your KaVo KEY 3 certification, you will be encouraged to look at your current practice to see if there are certain procedures you may wish to attempt with the use of the laser in your practice.

A Successful Recipe

One of the challenges many dental professionals face is in taking a look at the bigger

picture. Certainly the intent of this pre-certification on laser technology is not to address the generalities of business practice management as a whole, but it is important, regardless of what your role is within the office setting, to understand that the laser is simply one more tool in your arsenal to provide excellent patient care. We have to remember that we have made the investment in the technology – but that it will not implement itself. Everyone plays a role!


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At a high level, the ingredients to successful laser implementation include:

Leadership from within all levels of a team

Communication

o Within the team setting; and

o With your patients

Marketing lasers as part of your internal and/or external advertising

Ensuring the team is empowered and trained on how to use the

technology

Understanding the regulatory requirements in your province or Territory

on who can use the laser and for what purpose

Pairing and promoting laser with other technology advancements in your

practice, if you have them

Combining laser treatment with other best practices

Managing your schedule

Checklists

From a business perspective, here are a few simple things that could assist in your day-to-day operations:

Assign a “laser officer” in your office to coordinate maintenance or repair calls as a single point of contact

The clinical team and the administrative team need a meeting (or meetings) to discuss how to schedule laser treatment into your day

Ensure you keep an appropriate inventory of supplies for your laser (the details of this will be discussed in certification)

Your Sinclair representative will be able to assist you on certain particulars of the laser, but here are some important points to keep in mind:

These are delicate pieces of equipment. Although they have an inherit robustness about them, they cannot be banged into walls nor handled roughly over tiled floors and thresholds. Take time and care when you are moving it within the office.


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Be sure to use the handle on the front to guide and move it and not the swivel arm for the optical line. The swivel is fragile and will break if you pry on it or use it to steer the machine.

The laser requires dedicated electrical circuitry within your office. Only plug the laser into receptacles that been wired to accommodate it

Maintain the laser and the hand pieces carefully! The sterilization and maintenance procedures for the hand pieces differ from one to another. It can be a very costly mistake if you do not maintain the unit and its pieces according to the manufacturer recommendations.

Given the flexibility associated with the integration of this technology, there are a number of different ways an office can operate effectively and efficiently with the laser. In all likelihood, one of your biggest challenges will be scheduling the laser between hygiene and restorative rooms. Again, while each office may choose to do this within the context of their own internal procedures, your certification instructor will provide some additional input on how you may wish to proceed. With some teamwork and good discussion within your office, you will likely find a solution that will work for you.


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Conclusion & Wrap-Up

Taking the Next Steps!

Now that you have finished reading this self study guide, you can proceed to completing the enclosed exam. Please understand that regulatory bodies under most jurisdictions require that a comprehensive training program is completed by each practitioner when using any form of dental laser. You are more than welcome to reference the self-study guide while you complete the examination – understanding this is the pre-requisite course to your full-day certification program which will be scheduled for you within the coming weeks.

Clearly there is a good deal of information in this document which will form the foundation of your knowledge of laser dentistry. You are encouraged to make a list of any questions you may have regarding laser therapy so that you can present them to your certification instructor at a later date. Please keep in mind that this self study module was put in place in order to bring all certification participants up to a similar level of comprehension. If you would like to delve further into the scientific background, documented studies are available for your review – and you are welcome to ask your local Sinclair sales representative for assistance in obtaining copies.

Now, please complete your Exam and enclosed Registration Form. These documents must be completed and received by Sinclair Dental prior to your enrollment in the certification program – so it is imperative that you return these documents as quickly as possible following receipt of this package.

In closing, and on behalf of KaVo International and Sinclair Dental Canada, we wish you years of success and professional excellence in the use of your KaVo KEY 3 laser!

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Acknowledgements

This self-study module was written by Stephen Smith in partnership with Dr. Barton Walters for Sinclair Dental. Content for this program has been gleaned from the two-day Evolve Your Practice: Introduction to Laser Dentistry workshop series presented by Sinclair Dental and featuring lecturers Dr. Barton Walters, Jo-Anne Jones, RDH – and Stephen Smith of DentalBizz Practice Innovators. The authors acknowledge input from information sources provided to them, including:

Presentation Material from KaVo Germany

Presentation Material provided by SciCan Canada

Jo-Anne Jones, RDH

Numerous Scientific Studies available through the Laser Technology Division at Sinclair Dental

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