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Think Before You Treat
Thoughts for the successful implementation of lasers into practice.
By Scott D. Benjamin, DDS
The successful implementation of any technology into a dental practice, especially lasers, requires comprehensive planning, selection, organization, and training to make the transition efficacious. The entire dental team needs to be involved in this process. With all procedures, positive outcomes are directly related to a group effort. Incorporating the “Six Ws” (sometimes referred to as the “Five Ws and One H”) that we learned in elementary school—Who, What, Why, Where, When, and How—into the process can really assist in simplifying the implementation.
Who is going to use the laser (dentist and/or hygienist) and who are the types of patients that are going to receive laser care? What procedures are to be performed and what are the ancillary supplies required for the procedures? Why are we incorporating laser care into the practice? Where are the procedures going to be performed? When are the procedures going to be performed? Is laser debridement going to be part of scaling and root planing procedures? Is soft tissue troughing going to be part of crown-and-bridge impression appointments in place of retraction cord? How are the laser procedures going to be introduced and explained to the patient?
The first and most major step in the process is identifying the true needs of the practice and what benefits laser technology will bring to patient care. Just as the needs of every practice and patient are different, the science, functionality, dependability, and ergonomics of every laser are different. An important goal to remember is that all technology serves only two roles in the practice. The first and most important is that all technology needs to enhance the quality of care that we deliver to our patients. The other role is to improve the efficiency in which quality care can be administered. These considerations need to be at the forefront in the selection of proper laser devices for the practice.
When evaluating the different lasers that are available in the marketplace today, considerations need to be made for the procedures it can perform, the ease of performing those procedures, and the quality of the outcomes obtainable. From the feature perspective, wavelength, peak power, and control over the tissue interactions are all important aspects that need to be evaluated. Attention should also be focused on dependability and reliability of the company and specific training available from that company on the device.
While the upfront cost of the device is a concern, a more important matter to consider is the per-patient cost and the ongoing expenses related to maintaining the device. Device-specific training is essential and more and more states are starting to require a full-day hands-on training before the device can be registered and used in patient care. Before acquiring a laser, clinicians need to investigate their state regulations and make sure that the necessary training is available through their manufacturers or dealers. For education in addition to that supplied by the manufacturer, the Academy of Laser Dentistry (ALD) is an excellent resource for additional information and education on the safe and effective use of lasers in dentistry. The ALD’s annual conference is a multi-day meeting focused specifically on the efficient implementation of lasers into everyday practice.
Ergonomic considerations include how easily the device can be transported and used in multiple operatories if so desired, and the placement of the device while the procedures are being performed. This is especially important if the laser is going to be used both by the dentist and the hygienist. The ability of lasers to perform many different procedures and the need for the clinician to adjust the parameters for different procedures and tissue types makes the user interface a very important ergonomic consideration. Also, a thorough understanding of the proper infection control procedures required for each device needs to be evaluated in the selection process. These concerns cannot be overstated and, unfortunately, are often overlooked.
Once the laser has been selected, the logical next step is for all of the clinicians using the device to be properly trained on set-up, infection control procedures, and patient treatment procedures and protocols. The entire clinical staff—including dentists, hygienists, and all clinical auxiliaries—need to be properly trained and may be required to be trained by individual state regulations. Regardless of whether the state dental board or regulatory agencies require training and registering the laser, the American National Standards (ANSI) requires every clinician who uses a Class IV laser to be trained. ANSI standard also requires that every facility that used a Class IIIB or IV laser have a trained and designated laser safety officer (LSO).1,2
It is the responsibility of the LSO to ensure that all appropriate safety protocols are followed. Some of the duties of the LSO are to define the nominal hazard zone (NHZ) for each area that the lasers are to being used, ensure that the signage and laser safety glasses are appropriate and in good repair, that the laser devices are properly labeled, and that all staff members have been appropriately educated on laser safety procedures.
While specific training is not required for nonclinical personnel in the dental practice, it is required that all personnel in a facility where lasers are in use be trained on the basic safety considerations for laser use. Most importantly is an understanding of the NHZ, the potentially dangerous area, when a laser is in use (which is normally the entire operatory). The NHZ is required to be identified with laser safety signs posted at the entrance to the area. These signs, if used properly, not only designate the NHZ for the laser, but also serve as a potential marketing tool for other patients passing by these entrances initiating discussions with other patients on the benefits of laser therapy and patient care.
The administrative staff, while not being directly involved in administering laser therapy, need to be involved with understanding the benefits and values that the laser brings to the practice and patient care as they are the ones who most often interface with the patients on the telephone. The administrative staff also needs to be trained on the proper procedures for billing and insurance narratives that may be required to ensure proper reimbursement. An important consideration to understand is that there are no specific ADA CDT codes for laser treatment or therapy (except for “D7465 distraction of lesion(s) by physical or chemical method, by report.” Examples include using cryo, laser, or electro surgery.3) Lasers are adjunct devices used to assist in the performance of procedures similar to that of a high-speed handpiece, ultrasonic scaler, or a scalpel; thus, the appropriate code for the procedure performed is used for reimbursement. No additional notes or comments are required or should be submitted other than those routinely required by report for the procedure performed.
All lasers require various accessory supplies for treatment. All of the components and accessory materials that are needed for treatment should be established and organized well in advance before the patient is scheduled. Incorporating lasers into a dental practice can often cause workflow issues initially that greatly impede efficiency and how procedures are performed. With careful forethought and planning, a lot of these issues can be avoided. Configuring a tub system that contains all of the necessary accessory components for laser therapy will often simplify the process. With the appropriate systems, this tub can contain items such as laser safety glasses, cleaving tools, extra fibers, extra tips/cannulas, bending tools for the tips, initiating materials (if required), appropriate topical anesthetics, laser safety signs, and any other materials necessary to perform the desired treatments.
Some lasers, especially those in the Erbium, Nd:YAG, and carbon dioxide classes, are quite large and may impede the movement of the clinical staff and the patient, so establishing the appropriate placement and/or movement of the devices is essential. Tabletop models that require being plugged into a wall outlet often pose a problem when the location of the electrical outlet is not in a convenient location compared to where the laser would ideally be placed. If a foot controller is required, it further complicates the efficiency and how the device can be moved from room to room. It is recommended that all of these workflow issues be reviewed and addressed in each operatory before a patient is scheduled in that area.
Once all of the above issues have been addressed, the practice needs to determine which operatories are most appropriate for laser therapy. When this has been recognized, then appropriate scheduling patterns can be established. It is recommended that for the first few procedures, additional time be allocated to the appointments to minimize the stress of both the clinician and patient. It is also recommended that the first few procedures be performed in areas with good visibility and accessibility and on patients with whom the clinicians are familiar. Minimizing some of the variables involved with laser therapy will enhance the clinician’s ability to obtain the desired outcomes.
With proper forethought, selection, and planning, the incorporation of laser therapy into a dental practice can greatly enhance the quality of care patients receive and increase the efficiency in which care is delivered, minimizing stress for the patients and the entire dental team and improving treatment outcomes, which is the true goal for all technologies and treatment modalities.
1. Laser Institute of America. American National Standard for the Safe Use of Lasers. ANSIZ-136.1-2007.
2. Laser Institute of America. American National Standard for the Safe Use of Lasers In Health Care. ANSI Z-136.3-2005.
3. American Dental Association. CDT 2011-2012 Current Dental Terminology.
About the Author
Scott D. Benjamin, DDS
Sidney, New York