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Charter College

Abstract
In oral health care, the number and range of laser-based technologies have expanded enormously over the past two decades. The scope of this paper is to alert the dental professional to the extent, application, and responsibilities associated with safety when using lasers designed for use in dentistry. By far, the majority of laser instruments are within the private (nonhospital) clinic setting. Laser use extends from those procedures of a diagnostic or nonsurgical (bio stimulatory or photochemical) nature, to more powerful devices that are used in surgical procedures. Low-powered lasers may deliver energy of a few millijoules, whereas surgical lasers may have pulsed emission modes capable of peak power delivery in excess of 1,000 Watts. Laser radiation can be dangerous, because it is concentrated and powerful. This paper draws upon the standards outlined by the International Electro-technical Commission

Keywords: ANSI: American National Standards Institute. A not-for-profit organization, founded in 1918, that oversees the administration and coordination of the United States private sector voluntary standardization system.
OSHA: Occupational Safety and Health Administration. A division of the U.S. Department of Labor, OSHA serves to ensure safety and health in the workplace. Created in 1971.

FDA: The U.S. Food and Drug Administration, a division of the U.S. Department of Health and Human Services. Founded through consolidation in 1930. The FDA enacts the provisions of the
Federal Food, Drug and Cosmetic Act (rev. 2004). The FDA Center for Devices and Radiological Health (CDRH) is responsible for the premarket approval of all medical devices, as well as overseeing the manufacturing, performance and safety of these devices.

IEC: International Electrotechnical Commission. Founded in 1906, the IEC is a not-for-profit, nongovernmental international organization that prepares and publishes international standards for all electrical, electronic, and related technologies. The headquarters are in Geneva, Switzerland.

NHZ: Nominal Hazard Zone. This is the space within which the
Maximum Permissible Exposure (MPE) is being exceeded.

MPE:Maximum Permissible Exposure. This represents a value of exposure to laser energy above which a risk of target damage may occur. MPE values are applied to the unprotected eye and skin.

OD: Optical Density. The ability of the glass or polycarbonate shield to attenuate the laser beam. The opacity of the protective filter.

NOD HD:Nominal Ocular Hazard Distance. That distance from the emission port of the laser beyond which any exposure is within MPE values.

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Laser use in general dental practice has grown considerably over the past 20 years, both in numbers and scope of use. The registered laser owner is responsible for ensuring that all personnel have a thorough knowledge of laser safety. There exists a duty of care to all dental health care professionals in the application of lasers in clinical practice. Such regulations may exist through federal and/or international standards. The duty of care extends to all staff as well as patients. General and specific measures must be employed to ensure the safe use of lasers in dentistry. Laser safety is applicable according to the class of laser being used. There is a basic requirement of the clinician and associated staff to ensure that laser use is carried out within a safe environment.
Key to this requirement is an understanding of the device being used, laser physics, and adherence to federal, national, and international statutes. These regulations may apply either specifically to laser use or within broader health and safety legislation. Laser safety considerations are proportional to established and recognized risk. The potential maximum power output will define a basic approach, but specific to more powerful lasers are measures taken to address additional risks of laser damage to nontarget oral tissue, skin, and eyes. Such damage may be the result of direct exposure to the laser beam or through the combustion of chemicals, gases, and materials used in dentistry. The protection of those personnel involved in laser treatment – patient and staff – is a prime consideration, but it is also important to consider those measures required to safeguard against any risk events.
History can provide us with records of injuries occurring to people due to lasers. The U.S. military, FDA, U.S. Department of Energy, U.K. Medicines and Healthcare Regulatory Agency, and Rockwell Laser Industries, to name a few, maintain logs of laser-related incidents through their device-reporting mechanisms. The following anecdotes provide us with some insight into the extent of injuries and consequences of such accidents. Incidents include lasers that fail to stop after the foot pedal has been released; burns to lips, tongue, and cheeks; firemen entering a surgery in response to a smoke alarm, unaware that a laser was in operation. Other incidents include injuries due to the laser beam being reflected off a droplet. Incidents specific to eyes include an injury because the Manufacturer sent the doctor the wrong goggles specific to the laser wavelength being used and the doctor did not double-check the eyewear designation. Another recorded incident involved a university assistant suing for $39 million after she sustained a laser eye injury in a laboratory setting. A key factor in her case was that the professors were reported as not adhering to wearing the safety goggles, giving subordinates the impression that the protective eyewear was not necessary. The assistant settled for $1 million. These are just some examples of the nature of laser injuries that can occur, the majority of which can be traced back to poor adherence to established safety protocols.

All lasers used in dentistry are categorized with regard to the potential for damage, extending from Class I lasers, which may pose no implicit risk, to Class IV lasers for which all safety measures are applicable. Regardless of the class of laser being used, it is advised that one should never look directly into a laser beam, even if it is considered to be “eye-safe.” The classification ascends from
Class I through Class IV, with Class I being considered eye-safe and Class IV being the most dangerous. However, with the increased use of magnification devices – loupes and microscopes – there is a potential for laser beams to be magnified and/or focused. Consequently, Class IM and Class IIM contain refinements. Class IIIR and IIIB lasers are generally low-level instruments, whose wavelengths are in the red part of the electromagnetic spectrum and whose energy range lies between 1 and 500 milliWatts. They require safety personnel to monitor the Nominal Hazard Zone
(NHZ), eye protection, and training. Class IIIR was recognized to include those continuous-wave lasers that may emit up to five times the power of Class I and II lasers.
Laser use in dentistry is proven to be beneficial in treating a wide range of dental conditions as well as a therapeutic tool in tissue management. The dynamics of laser energy beams pose general risks to non-oral tissues and the immediate environment of such use must be deemed at risk from direct or scattered exposure. Safety measures have been devised to safeguard those personnel – staff and patients – who may be involved in dental treatment using lasers. Most safety measures are the product of official regulatory bodies such as ANSI, OSHA, FDA, and IEC, but additional measures may be the product of individual needs within particular dental offices and consequently recorded in local rules. The reader is encouraged to consult these regulatory bodies as they may apply on a national or regional basis, to ensure a correct and responsible compliance with all laser safety measures in the treatment of dental patients. The analysis of general and specific risk during laser use has been addressed through many statutory instruments and all clinical procedures should be measured against such standards, in order to offer the maximum protection for the patient, clinical staff, and those within the immediate environment.

References 1. Moseley H. Operator error is the key factor contributing to medical laser accidents. Lasers Med Sci 2004; 19(2):105-111.

2. Adverse event report. Available at: U.S. Food and Drug Administration. Center for Devices and Radiological Health. Adverse event report. Candela Corp. Vbeam laser dermatology laser.

3. Barat K. Laser safety management. Boca Raton, Fla: CRC Press/ Taylor & Francis Group, LLC, 2006:129.

4. American national standard for the safe use of lasers. ANSI Z136.1 – 2 0 07. Orlando, Fla: The Laser Institute of America, 2007:1.2, 2-3.