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Journal of | 2012 Vol. 20, No. 2 O SITI Laser safety is applicable according to the class of laser being used. used. being according laser to class of the is applicable safety Laser in dentistry. of use safe ensureto the employed be measures must specific and General patients. aswell as all staff to extends care of duty The and/or standards. international federal through may exist regulations Such practice. in clinical lasers of application in the professionals care to health care allof dental aduty exists There safety. laser of knowledge have athorough that all personnel ensuring for is responsible owner laser registered use. The of scope and in numbers 20 both years, past over the considerably grown has practice dental in general use Laser of terms. definitions and acronyms of 62 explanations for page on to Glossary the Refer remain constant. will instrument laser a of use safe the of principle however,manuscript; fundamental the this of revision may dictate in technology changes course, Of 2009. in February Directors of Board Academy’s bythe approved was safety laser on paper This in dentistry. lasers of uses the on Dentistry, Laser of Academy the of Committee Research and Science bythe written papers position of aseries of second is the This Sweeney et al. et Sweeney J LaserDent John G.Sulewski,MA;JoelM.White,DDS,MS Donald J.Coluzzi,DDS;PennyParker,RDN;StevenP.A.BDS,LDS,MFGDP; Caroline Sweeney,MBA,MA,BSc,OTR(CommitteeChair); Laser SafetyCommittee,AcademyofDentistry Laser Safety in Dentistry: APosition Paper S EDIT O U MMARY N PAPERN O R’S NO

2009;17(1):39-49 TE

abstract it is concentrated and powerful. it isconcentrated andpowerful. of 1,000 Watts. Laserradiationcanbedangerous, because inexcessemission modescapableofpeakpower delivery few millijoules, whereas surgical lasersmay have pulsed procedures. Low-powered lasersmay deliver energy ofa thatare devices to usedinsurgical more powerful orphotochemical) nature,nonsurgical (biostimulatory fromuse extends thoseprocedures ofadiagnostic or are (nonhospital)clinic setting. withintheprivate Laser far,use indentistry. By oflaserinstruments themajority associated withsafety whenusinglasersdesigned for professional application,andresponsibilities to theextent, decades.two thedental The scopeof thispaperisto alert technologies have over expandedenormously thepast oralhealthcare,In thenumberandrangeoflaser-based examinations oftheAcademy ofLaserDentistry. Laser Education thatisrequired by the certification GuidelinesandStandardsthe Curriculum for Dental outlinedin complements thecore ofknowledge addition,interpretation ofthesestandardsIn Lasers inHealthCare Facilities. Z136.3 –2005American Useof NationalStandard fortheSafe American UseofLasers NationalStandard andANSI forSafe NationalStandards ANSIZ136.1–2007 American Institute 1: Equipment classification and requirements) andthe oflaserproducts –Part 1, Edition 2.0,2007-03.Safety Electrotechnical Commission (IEC60825- International byexplicitly orimplicitlywithregard the to dentistry) This paperdraws uponthestandards outlined(either POSITION PAPER

INTRODUCTION LASER CLASSIFICATIONS There is a basic requirement of the clinician and associated staff to All lasers used in dentistry are categorized with regard to the ensure that laser use is carried out within a safe environment. Key potential for damage, extending from Class I lasers, which may to this requirement is an understanding of the device being used, pose no implicit risk, to Class IV lasers for which all safety measures laser physics, and adherence to federal, national, and international are applicable.4 Regardless of the class of laser being used, it is statutes. These regulations may apply either specifically to laser advised that one should never look directly into a laser beam, even use or within broader health and safety legislation. 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 Laser safety considerations are proportional to established and Class IV being the most dangerous. However, with the increased recognized risk. The potential maximum power output will use of magnification devices – loupes and microscopes – there define a basic approach, but specific to more powerful lasers is a potential for laser beams to be magnified and/or focused. are measures taken to address additional risks of laser damage Consequently, Class IM and Class IIM contain refinements. to nontarget oral tissue, skin, and eyes. Such damage may be the result of direct exposure to the laser beam or through the Class IIIR and IIIB lasers are generally low-level instruments, whose combustion of chemicals, gases, and materials used in dentistry. wavelengths are in the red part of the electromagnetic spectrum The protection of those personnel involved in laser treatment – and whose energy range lies between 1 and 500 milliWatts. They patient and staff – is a prime consideration, but it is also important require safety personnel to monitor the Nominal Hazard Zone to consider those measures required to safeguard against any (NHZ), eye protection, and training. risk events. Class IIIR was recognized to include those continuous-wave lasers History can provide us with records of injuries occurring to people that may emit up to five times the power of Class I and II lasers.5 due to lasers. The U.S. military, FDA, U.S. Department of Energy, U.K. These lasers pose significant risk of eye damage, and the eyewear Medicines and Healthcare Regulatory Agency, and Rockwell Laser must be rated at minimum Optical Density (OD) in the United Industries, to name a few, maintain logs of laser-related incidents States (U.S.) or European L6A standard. It is the laser manufacturer’s through their device-reporting mechanisms. The following responsibility to provide the numerical value of the OD, in the anecdotes provide us with some insight into the extent of injuries operator’s manual, specific to the laser being used. and consequences of such accidents. Incidents include lasers Table 1 provides an outline of the basic classes of lasers, the that fail to stop after the foot pedal has been released; burns to delineated emission parameters, examples of uses of each class lips, tongue, and cheeks; firemen entering a surgery in response within dentistry, risks posed to unprotected tissue, and safety to a smoke alarm, unaware that a laser was in operation.1 Other measures. For clarification, it should be noted that the blink incidents include injuries due to the laser beam being reflected off response is one of the responses that is encompassed within the a droplet.1 Incidents specific to eyes include an injury because the aversion response. The aversion response consists of blinking and manufacturer sent the doctor the wrong goggles specific to the turning one’s head away from the beam path. laser wavelength being used and the doctor did not double-check the eyewear designation.2 Another recorded incident involved Class IV lasers, which are surgical devices, require safety personnel a university assistant suing for $39 million after she sustained a to monitor the NHZ, eye protection, and training. These lasers laser eye injury in a laboratory setting. A key factor in her case pose significant risk of damage to eyes, any nontarget tissue, was that the professors were reported as not adhering to wearing and can produce plume hazards. Plume, in the context of this the safety goggles, giving subordinates the impression that the paper, is defined as the gaseous by-products and debris from protective eyewear was not necessary. The assistant settled for laser-tissue interaction. It can have a smoky appearance or be $1 million.3 These are just some examples of the nature of laser completely invisible to the naked eye. With Class IV lasers, eyewear injuries that can occur, the majority of which can be traced back to must be rated at a minimum OD 5. It is the laser manufacturer’s poor adherence to established safety protocols. responsibility to ensure that the device class is clearly marked on the laser machine and in certain countries it is required to post such information at all access points to the area in which the laser is being operated. It is the responsibility of the Laser Safety Officer (LSO) to ensure that the safety measures appropriate to each laser class are applied and made known to all staff. It is not the manufacturer’s responsibility to provide the dentist with training in this aspect. However, in the United States, federal regulations require manufacturers to provide certain safety information related to their laser in the laser operator’s manual. The computation, in feet or meters, of the NHZ of the laser is a calculation that is generally beyond the scope of the dentist or LSO. Monitoring and calculating the NHZ are two different issues. It is the manufacturers’ responsibility to calculate what the NHZ distance is and have that information posted in the operator’s manual. It is the LSO’s responsibility to read the manual, ensure that the NHZ around the laser in the dental practice is identified, and personnel adhere to the safety measures. Journal of Laser Dentistry | 2012 Vol. 20,No. 2 Sweeney et al. 55 56 P

Journal of Laser Dentistry | 2012 Vol. 20, No. 2 O SITI assessed. be can (NOHD) Distance Hazard Ocular Nominal a configuration, and diameter beam divergence, and of amount output, power the on Based distance. with divergence some undergo will system adelivery exiting beams laser most asin practice theoretical, as follows: listed may be hazards tissue. Laser target of ablation the or laser the with associated and/orair either water supplies) chemicals and cables, (electrical, device the from arising also but itself, beam laser the with only not associated are dangers there risk, instantaneous or predictable –that pose IV –IIIB and classes to regard those With care. with handled be should class, of regardless devices, Laser Sweeney et al. et Sweeney HAZARDS HAZARDS O Class IV Class IIIB Class IIIR Class IIM Class II Class IM Class I • Other collective hazards. collective • Other • Fire • Chemical • Skin tissue oral • Nontarget • Optical The concept of laser beam collimation may be considered considered may collimation be beam laser concept of The N PAPERN Laser Class 7

Table Classification, 1:Laser PowerRisk Output,Analysis and No upperlimit 0.5 Watt Invisible 2.0milliWatts Visible 5.0milliWatts 1.0 milliWatt 400 µWatts(red) 40 µWatts(blue) Maximum Output All surgicallasers devices chemofluorescent Mucosal scanning devices chemotherapy anti-microbial Photodynamic Low-level lasers Aiming beams Laser cariesdetection Aiming beams Scanner Laser cariesdetection Dentistry Use in Plume hazard Fire hazard damage Nontarget tissue Eye andskindamage skin risk pose slightfireand Maximum outputmay Eye damage Eye damage (Class IIM) magnified beam Significant riskwith direct viewing Possible riskwith (Class IM) magnified beam Possible riskwith No implicitrisk by publishing this information in the operator’s manual. manual. operator’s in the this information by publishing NHZ specific laser’s dental the of LSO and dentist the informing of responsibility the has all Er:YAGfor manufacturer The is 2feet. lasers NHZ to that the say is it incorrect wavelengths; laser other for said be also can same The lasers. all diode for 8feet example, is, for laser 810-nm an NHZ to for that the say diode is correct it not Therefore, power. output maximum of 5Watts with laser nm diode have will adifferentNHZ another than 3Watts of 810- output power amaximum 810-nm an with laser NHZ area example, For is. diode the large how determine Many factors taken. be measures must (NHZ), Zone protective Hazard Nominal the this area, called Within MPE. to the is above exposed is being that aperson radiation or structures. tissue nontarget and target and beam, the of focusing possible diameter, beam output, power relative to wavelength, laser applied be can may occur. MPE tissue value damage which The above limit (MPE). exposure of is avalue Exposure This Permissible Maximum Possible Within a certain space around a Class IV laser, the level of laser laser, aClass laser IV of around space level the acertain Within The possible risk to human tissue is assessed with regard to regard the with risk to tissue human is assessed possible The Hazard 8-9

regulations Possible registrationtocomplywithnational Training andlocalrules Safety personnel Safety eyewear Training forClassIIIRandIIIBlasers Safety personnel Safety eyewear Laser safetylabels Sight aversionresponse Laser safetylabels Blink response Measures Safety 4

POSITION PAPER

EYE HAZARDS The eye is composed of pigmented and nonpigmented tissue that will absorb incident laser radiation relative to the wavelength being used. Damage from a laser beam may be due to direct exposure of the unprotected eye or diffuse reflection and is ever-present in those situations where wavelength-specific protective eyewear is not worn. Damage also depends on the type of laser being used, since a free-running pulsed laser will cause more damage than a continuous laser of equal power.10 This is because the output power of a free-running pulsed laser can achieve high peak power surges in a short pulse followed by long off-time durations. Its peak power is considerably greater than its average output power. For a continuous-wave laser, the output power and the peak power are the same, regardless of whether it is used in a continuous or gated Figure 1: Prime risk structures of the eye at risk vs. laser wavelength (nm). mode. In addition, the ability of the eye’s lens to focus incident light Graphic produced by Dr. Steven Parker. may significantly increase the hazard posed by those wavelengths that may enter the eye.11 In current clinical dental use, shorter laser wavelengths (visible to near-infrared, 400-1400 nm), being relatively nonabsorbed by water, may result in retinal burns in the area of the optic disc. Some visible wavelengths may selectively damage green The protocol for use is “patient first on and last off.” This means or red cones in the retina, producing color blindness. In addition, that as soon as the patient is seated in the dental chair, he or she is the 700-1400-nm wavelengths can cause lens damage. The second to put on the appropriate laser eyewear, which is not to be taken group of wavelengths, the longer wavelengths (mid- to far-infrared, off until the patient is leaving the dental operatory at the end of the 1,400-10,600 nm) have high absorption in water, and corneal, procedure. The dental operatory personnel must don the eyewear aqueous, and lens damage is associated with these wavelengths.12 prior to the laser being turned on and not take them off until the Consequently, it is mandatory that all personnel (clinician, laser is switched off or put into standby mode. assistant, and patient) within the controlled area of Class IIIB, IIIR, Care must be taken when cleaning laser eyewear and side and IV laser use should employ suitable eye protection during laser shields so that their protective coating is not destroyed. The procedures. Measures must be taken to protect the eyes of the eyewear should be washed with antibacterial soap and dried with a staff and patients when the MPE is exceeded, i.e., when the dental soft cotton cloth in between procedures and patients. Disinfecting laser is on and people are within the NHZ. Eyewear should be solutions generally applied to dental surfaces are too caustic and constructed of wavelength-specific material to attenuate the laser should be avoided. The eyewear must be inspected frequently energy or to contain the energy within MPE values. Standards that to determine whether there is any breakdown (lifting / cracking / specify the nature and suitability of laser protective eyewear are flaking) of the protective material that would render the eyewear to contained in ANSI (ANSI Z136.1 – 2007) for North American users, EN be useless. 207/208 for European users, and IEC (IEC 60825) for all other regions. The manufacturer’s mark must be imprinted on the eyewear. The wavelength or wavelengths that the protective eyewear is specific for must be stamped on the glass or side shields. If the eyewear is marked as 810 nm – 2890 nm, then this means that the eyes exposed to all wavelengths between these two outer limits are protected. If one line states 810 nm and then underneath 2890 nm is stamped, it means that eyes are protected only against these two wavelengths and no protection is provided for wavelengths in between. In addition, the OD is required to be stamped clearly onto the glass or polycarbonate side frames for North America while references to the OD, CE mark, operation mode (DIR), protective grade (L6A), and Direct Impact Number (DIN) are displayed in Europe. Please refer to the glossary provided for additional information. Practitioners using loupes must wear the appropriate protective insert or shield. Glasses and goggles must cover the entire periorbital region, be free of any surface scratches or damage, and be fitted with suitable side panels to prevent diffuse laser beam entry. Practitioners using a microscope must fit the appropriate filters and maintain close eye contact with the oculars. Journal of Laser Dentistry | 2012 Vol. 20, No. 2

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Journal of Laser Dentistry | 2012 Vol. 20, No. 2 O SITI reduce the clinician’s wider field of vision. vision. of clinician’s the field reduce wider that might accessory other or is using amicroscope dentist the if especially situation, dental the in monitoring arole play as they tissue change unexpected or adverse in recognizing trained to be need Assistants treatment is ensured. of to time be at the present unwanted reflection. totaken possible minimize measures safely, are providing used may be mirrors rhodium or may shatter. and steel Stainless energy laser the heat from absorb water, hydroxyapatite, and melanin in oral tissue)water, in oral melanin and hydroxyapatite, ashemoglobin, such energy laser light or that absorb compounds (molecular chromophores multiple of approximation close tissue. to The nontarget adjacent or damage accidental and access in risks specific pose cavity oral the of constraints The of the coating. the of to ensure integrity regularly inspected be should instruments ebonized) (i.e., Coated employed. be should instruments finished matte- or dull, nonreflective, Anodized, adjacent tissues. damaging avoid accidentally tissue and onto target beam the the focus to energy, is using required laser procedure attention ablation any surgical During tissues. other of unintentional vaporization to avoid wavelength any laser of surgical use the during care Sweeney et al. et Sweeney N O CO Er:YAG 2940nm Er,Cr:YSGG 2780nm Ho:YAG 2100nm Nd:YAG 1064nm microscopes, assuchmagnification instruments canmakeadiverging beammore hazardous. lasersmay become hazardous to* ClassIandIIcaries-detection theretina whenviewed through opticalaids, e.g., eye loupesand Diode 810-980nm cytofluorescent devices 630-900nm andoralCaries pathology detection Argon 488-514nm O Parallel monitoring of the adjacent tissues by all dental staff staff adjacent byall tissues dental the of monitoring Parallel 2 N PAPERN NTARGET O 10,600 nm 17 Glass mirrors should not be used because they they because used be not should mirrors Glass Laser RAL TISS RAL Table 2:Eye Hazards andSkin ofDental Lasers U E HAZARDS HAZARDS E Cornea Aqueous Humor Lens Cornea Aqueous Humor Lens Cornea Aqueous Humor Lens Lens Retina Lens Retina Cornea Lens (above 700nm) below*See Retina 16 16 demands demands Eye Structure Laser plume poses a significant hazard asignificant poses plume Laser size. spot and exposure, laser of duration beam, laser the of value density power the wavelengths), with together (longer water wavelengths) and (chromophores) (shorter aspigment such potential relative to tissue elements the wavelength’s absorptive laser particular is the damage in structural factor governing The (1400-10,600 structures. wavelengths surface with nm) interact will far-infrared to Mid- respectively. structures deeper and superficial into nm) the epidermis the potential haveto through the pass (400-1400 wavelengths near-infrared and Visible warming. tissue reversible than threat, other little pose will levels power energy. laser incident Subablative the and structure skin the of threshold relative to ablation the be will lasers to IV Class III Band exposure inadvertent through to skin the Any damage potential for inorganic matter including viruses, toxic gases, and chemicals. chemicals. and toxic gases, viruses, including matter inorganic and organic contain particulate can products These interaction. to due laser-tissue by-products aerosol of development the of lasers are adequately protected against inadvertent skin exposure. exposure. skin inadvertent against protected are adequately lasers IV Class IIIB and of use in the involved that all those is important CHEMICAL HAZARDS CHEMICAL HAZARDS SKIN Corneal Burn Aqueous Flare Cataract Corneal Burn Aqueous Flare Cataract Corneal Burn Aqueous Flare Cataract Cataract Burn Retinal Cataract Burn Retinal Corneal Burn (above 700nm) andCataract Burn Retinal LesionRetinal LesionRetinal Eye Damage 15 15

Burns Blisters Excessive Dryness (400-700nm) Reactions Photosensitive 22 22 13 and occurs asaresult occurs and 14 14 Skin 18-21 It It POSITION PAPER

This is not unique to lasers, as it has been known that surgical point of some anesthetic aromatic hydrocarbons used in general instruments, such as electrosurgical equipment and dental anesthesia, and the presence of oxygen and nitrous oxide will handpieces, create surgical debris. American National Standard for support any combustion. Many materials that are not normally the Safe Use of Lasers in Health Care Facilities states that the hazard flammable may burn in an oxygen-enriched atmosphere.34 area for laser-generated airborne contaminates (LGACs) may be Endotracheal tubes need particular consideration to prevent the greater than the laser’s identified NHZ.23 Examples of the products laser beam from burning a hole in the tube and combusting with contained in LGAC include human papilloma virus, human the gases. Consequently, the tubes should be resistant to the laser immunodeficiency virus (suspected), carbon monoxide, hydrogen beam and have suitable coating, a wavelength-specific reflective cyanide, formaldehyde, benzene, acrolein, bacterial spores, and coating if possible, to prevent the possibility of combustion of the cancer cells.24 material and subsequent airway burns.35 Care should also be taken to prevent the build-up of blood onto endotracheal tubing, as this Of particular importance in restorative dental procedures, may lead to an increased fire hazard.36 other hazardous products may be present in the plume.25 During removal of composite resin with an erbium laser, along with the ejected whole resin particles, small amounts of free OTHER HAZARDS methacrylate monomer can be produced. Furthermore, although not an indication for use, directing the erbium laser’s energy onto Additional hazards associated with laser use include service and amalgam can produce mercury vapor, according to an in vitro mechanical hazards. Potential service hazards include electrical, study.26 This same precaution also applies to other lasers. water, and air supply lines and cables, as well as connectors and filters. The laser should be serviced regularly according to The hazard presented by the LGACs may include eye irritation, the manufacturer’s recommendations and only by qualified nausea, breathing difficulties, vomiting, and chest tightness personnel.37 The practitioner should inspect the supply lines and together with the possibility of transfer of infective bacteria and cables, clean and maintain the external portions of the laser, and viruses.24, 27-29 To combat such risk, regular surgical protective change necessary filters or other user-serviceable items. In addition, clothing must be employed and specific fine-mesh face masks many surgical lasers use a coaxial air or water supply which may capable of filtering 0.1-micron particles must be worn.30 Use of be under pressure. No attempt should be made to access internal high-speed evacuation must also be used. It has been determined parts of the machine during use. Capacitors can retain an energy that for carbon dioxide , the evacuation tube charge, even when the laser is no longer connected to the should be held as close as 1 cm from the target site; at 2 cm, the electrical supply outlet. evacuation ratio had diminished by 50%.31 Mechanical hazards include moving parts (e.g., articulating

arms). Laser machines employ multilevel safety features (fusible FIRE HAZARDS plugs, interlocks, pressure relief valves, and warning lights) to inactivate the machine in the event of a component failure. The high temperatures that are possible in the use of Class IV and Additional hazards may exist such as heavy articulated-arm delivery certain Class IIIB lasers can themselves either cause ignition of systems or the risk of needle-stick injury with fine quartz fiber-optic material and gases or promote flash-point ignition. ANSI Z136.3 has tips. Care must be taken around the cables and wires associated allowed gaseous conscious sedation procedures, such as the use with the laser, as tripping over and wrenching these cables and of a nose piece to deliver oxygen and nitrous oxide mixtures to fibers can be dangerous. Some machines are portable and, when be used during laser operation. However, a closed-circuit delivery moved, should be reassembled completely, ensuring stability. system must be used and a scavenging system must be connected to the high-volume evacuation to minimize gas leakage. Within the NHZ, use of aerosols, alcohol-soaked gauze, and INFECTION CONTROL alcohol-based anesthetics is to be avoided.32 Consequently, it is In the United States, the Centers for Disease Control and Prevention important to request that the patient remove any lip products that (CDC) have established infection control guidelines in a 2003 may contain an oil-based substance that is considered flammable, Morbidity and Mortality Weekly Report.38 Lasers in dental practices such as petroleum jelly. Additionally, tissue cleansing or preparation are to be considered as another . Dental agents that contain alcohol or other flammable chemicals carry practitioners and their team must follow standard precautions. specific risk of burning during laser use. If the patient carries an Standard precautions include use of personal protective oxygen tank, then the laser should not be utilized for the dental equipment (PPE) (e.g., gloves, masks, protective eyewear or procedure, unless the patient will remain comfortable with the face shield, and gowns) intended to prevent skin and mucous oxygen turned off and the nose cannula removed during the laser membrane exposures.39 portion of the procedure. Specific to lasers, any reusable fibers and tips must be heat- With general anesthetic procedures, there are three aspects to sterilized along with their handpieces, and not wiped with a be considered: high-level disinfectant. Any debris on the end of the tip must 1. Ignition sources (of which lasers are an example) be removed and/or cleaved off the end of the fiber to ensure 2. Fuel sources (gauze, drapes, preparation fluids, alcohol, and effective sterilization. The operator’s manual should contain anesthetic gases) recommendations about the sterilization process. For example, it 3. Oxygen-enriched atmosphere (more than 21% oxygen).33 is suggested that one does not sterilize the high-speed, lubricated

The laser energies used in tissue ablation may surpass the flash dental handpieces at the same time as the laser fibers so as to Journal of Laser Dentistry | 2012 Vol. 20, No. 2

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Journal of Laser Dentistry | 2012 Vol. 20, No. 2 O SITI Sweeney et al. et Sweeney O Safety features include the following: following: the features include Safety controls. over administrative possible, where preferred, always are and manufacturer controls bythe in place are set Engineering applications. in laser involved those protect and use unauthorized to prevent are designed regulations These features. built-in safety have IV) exclusively Class IIIBand not but (specifically devices laser regulations, successive agreed internationally Through onto fibers. the bag the through leaking handpieces the from oil of eliminate possibility the heat-sterilized. be also should acontaminated fiber on Any procedure. cleaver the used following disinfectant high-level with wiped be should environment dental the within surfaces and laser The possible. where covers) utilized be should barrier sticky universal sheaths, transparent protector sensor covers, (e.g., syringe barriers and sleeves hardware; protective all laser of contamination of to possibility shown the laser.controls be the on should Care over operational placed to be are recommended barriers wipeable or Removable trash. of in regular disposed be should optic fiber the position to used and handpiece the to fitted cannulas metal or fiber. the of Plastic pieces cleaved with along containers, sharps ENGINEERING C ENGINEERING • Visible signs on the laser, such as lights which warn whether whether laser, the warn signs on which suchaslights • Visible is it in when to laser the that is distinctive sound • Audible in left alaser that if so mode to standby default • Time-lapsed modes laser-emission and standby laser • Specific Internal messages. error and diagnostics software • Laser emission display to and ensure• Control panel correct easily located and –visible button or switch stop • Emergency to until emission the prevent laser shutters • Emission port being from to laser prevent the protection password or • Key a between aconnection constitute These interlocks. • Remote lockable be must present, if • Casters, (to switch foot prevent the accidental from response • Delayed to operation switch, prevent• Covered accidental foot access to internal to prevent panels unauthorized unit • Locked N PAPERN the laser is in standby mode or is being used. used. is being or mode is in standby laser the operation to laser initiate operate not will the mode “standby” in switch foot the Stepping on mode. to “standby” revert will laser the frame, time acertain within is used not mode “ready” is detected correctly that is functioning not component any when operations down that shut laser the within systems are set parameters process alengthy to through having go operator the without instant in an down shut be can laser that the so is attached system delivery correct are present not personnel authorized when operated laser the down shut will remote interlock the operation, laser during opened be door laser. the the and Should door closed switch) foot the on e.g., unintentional stepping operation, machinery 32 Disposable tips must be put into put be must tips Disposable O NTR O LS LS marketed in accordance with the standards in accordance the marketed with laser adental outcomes)to from prevent those that results intervention and hospitalization, injury, disability, life-threatening death, (including outcome or experience undesirable and serious a event is defined adverse an In this event. context, adverse an risk to of in order the minimize measures are required also safety controls, additional engineering to manufacturer’s the In addition Policies include: include: Policies implementation. their (LSO) to oversee Officer Safety aLaser of appointment the require and environment laser asafe facilitate to in order mechanisms aforementioned the supplement policies administrative These risk. to potential safety regard due their and responsibility with used be lasers that is allIt surgical essential or region. country that specific within use its governing regulations ADMINISTRATIVE C • The appointment of an LSO with specific responsibilities, responsibilities, specific with LSO an of appointment • The (SOPs) Procedures Standard Operating written • Establishing as follows: as follows: may apply asthey standards national other byANSI asrequired Z136.1 practice, dental the for –2007 and • Determines the controlled area and the potential hazard potential hazard area the and controlled the • Determines device the of limitations output the • Knows laser(s) the of characteristics operational the • Understands byauthorized operated is• Ensures being laser the last-and eyewear “first-on patient of • Ensures policy that the being eyewear is wavelength-specific • Ensures correct the eyewear protective the • Oversees the after signs down are• Ensures taken laser that the entryway at every signs are posted warning • Ensures correct this area within identifies NHZ, • Using manufacturer’s the laser(s) the of in characteristics operational the • Understands is needed laser anew when evaluation with • Assists team dental the of training and education the • Supervises suchasOSHA, standards, safety currentwith • Keeps is to authority This operation. laser to down shut • Authorized key in asafe the to secure key” the of “keeper asthe • Serves and nonhazard zones zones nonhazard and only personnel mode in standby placed or off turned is laser isthe finished,”and application laser the after off is and initiated laser “on the before dental team the is for policy The to. adhered is off” NOHD the within worn as“wallpaper” up left not and is completed, procedure used is being laser the in which into operatory the used being the laser office in accordancewith dental the practice the practice dental the with this information review, literature and updates and meetings educational through country) ANSI, appropriate the of IEC (or those LSO bythe held position employee dental the of regardless office dental in the respected and recognized be is in operation not laser the when place O NTR OLS 32 32 set forth by the bythe forth set POSITION PAPER

• Ensures laser maintenance, beam alignment, and calibration CONCLUSION is familiar with the biological and other potential hazards of the laser Laser use in dentistry is proven to be beneficial in treating a wide range of dental conditions as well as a therapeutic tool in • Supervises medical surveillance and incident reporting tissue management. The dynamics of laser energy beams pose • Keeps a log of recorded laser use and parameters employed general risks to non-oral tissues and the immediate environment of such use must be deemed at risk from direct or scattered • Ensures proper test-firing of the laser prior to admission of exposure. Safety measures have been devised to safeguard those the patient into the operatory. personnel – staff and patients – who may be involved in dental Laser test-firing is a safety measure designed to establish that the treatment using lasers. Most safety measures are the product of laser is working correctly and that there is patency of the delivery official regulatory bodies such as ANSI, OSHA, FDA, and IEC, but system. Test-firing should be carried out by the clinician or LSO additional measures may be the product of individual needs within prior to every procedure and before the patient is admitted to the particular dental offices and consequently recorded in local rules. controlled area. Protective eyewear is worn and all other safety The reader is encouraged to consult these regulatory bodies as measures met. The laser is directed toward a suitable absorbent they may apply on a national or regional basis, to ensure a correct material (e.g., water for longer wavelengths – 1400-11,000 nm, and and responsible compliance with all laser safety measures in the dark-colored paper for short wavelengths – 400-1400 nm) and treatment of dental patients. The analysis of general and specific operated at the lowest power setting for the laser being used. risk during laser use has been addressed through many statutory Test-firing will demonstrate that the laser is functioning properly, instruments and all clinical procedures should be measured all connections are securely in place, the delivery system is not against such standards, in order to offer the maximum damaged, and the laser beam is patent. protection for the patient, clinical staff, and those within the It is necessary to define a controlled area, within which all immediate environment. safety aspects pertaining to laser use are enforced. The LSO must follow the operator’s manual regarding the dimensions or limits of the controlled area. Dental clinics with multichair, open-plan environments need to address the physical dimensions and administrations of their controlled area in greater detail. Within the controlled area, all surfaces should be nonreflective, and measures should be taken to ensure that all supply cables for the laser along with its delicate delivery system are protected from inadvertent damage. A fire extinguisher should be sited for easy access. The LSO is required to oversee the training of the entire dental team with regard to lasers, including the nonuser and administrative staff. It is imperative that nonuser team members in the dental office are educated at some level with regard to the laser equipment and have received training on aspects of laser safety as they apply to their dental office. Regulatory agencies recognize the essential nature of appropriate training in laser use40-43 and there is an implied necessity that clinicians should receive training as part of their duty of care and dental licensing. The Standard Operating Procedure is a living, written document that outlines the existence and identity of laser devices within a given practice setting, personnel authorized to use the laser, and safety measures to address the hazards associated with the lasers in that particular dental practice. It contains all the local and national rules, including those set out in the aforementioned administrative controls. In the United States, ANSI Z136.1 – 2007 requires every dental practice with a laser to have such a document and many countries or regions have similar requirements. The Academy of Laser Dentistry adopted the Curriculum Guidelines and Standards for Dental Laser Education which defines a core of knowledge appropriate to the safe use of lasers in dentistry. All those clinicians passing proficiency examinations with the Academy will satisfy an acceptable level of competence in laser safety, and nonclinicians may take proficiency examinations to be recognized as laser safety officers. Journal of Laser Dentistry | 2012 Vol. 20, No. 2

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Journal of Laser Dentistry | 2012 Vol. 20, No. 2 O SITI Sweeney et al. et Sweeney O to attenuate thelaserbeam. oftheprotectiveThe opacity filter. OD: OpticalDensity. oftheglassorpolycarbonate shield The ability occur. MPEvaluesare appliedto theunprotected eye andskin. exposure to laserenergy above oftarget which arisk damagemay PermissibleMPE: Maximum Exposure. This represents avalueof PermissibleMaximum Exposure (MPE)isbeingexceeded. NHZ: NominalHazard Zone. This isthespacewithinwhich are Switzerland. inGeneva, headquarters for electronic, allelectrical, andrelated technologies. The organization thatprepares standards andpublishesinternational 1906, theIECisanot-for-profit, nongovernmental international Electrotechnical Commission. FoundedIEC: International in andsafety ofthesedevices. performance manufacturing, approvalpremarket ofallmedicaldevices, aswell asoverseeing the Health(CDRH)for isresponsible andRadiological Devices for the Federal Food, DrugandCosmetic (rev. Act 2004). The FDA Center consolidation in1930. The FDA theprovisions enacts ofthe Founded ofHealthandHumanServices. through Department FDA: The U.S. Food andDrugAdministration, adivisionoftheU.S. Createdhealth intheworkplace. in1971. ofLabor,of theU.S. to ensure Department safety and OSHAserves Directive (93/68/EEC) 1993. Directive (93/68/EEC) andusewithintheEuropeandistribution CEMarking Community “ConformitéCE Mark: Européenne” license approved for emission mode). exposure (continuous pulsed wave) or100pulses(free-running polycarbonate shield againstbeamdamage, relative to a10-sec Number.DIN: DirectImpact Astandard for theglassor industrial, orresearch conditions. thesuitability eyewearfor the L6A: Defines withinclinical, mode). (Q-switched intended, usingcoding “D” (continuous mode), “I” (pulsed mode), “R” relative to theemissionmodeof laser for whichtheeyewear is oftheglassorpolycarbonate toDIR: Ability attenuate thebeam MPE values. ofthelaserbeyond whichany exposure iswithin emission port HazardNOHD: NominalOcular Distance. That distancefrom the OSHA: standardization system. and coordination oftheUnited States voluntary sector private organization, founded in1918,thatoversees theadministration NationalStandardsANSI: American Institute. Anot-for-profit O GL N PAPERN

SSARY SSARY Occupational Safety andHealthAdministration.Occupational Adivision 6 bacterial spores.bacterial all microorganisms includingsubstantialnumbersofresistant Sterilization: Useofaphysical orchemicalprocedure to destroy spores.bacterial myobacteria, fungi,bacteria, andvirusesbutnothighnumbersof High-Level Disinfection: Process vegetative thatinactivates level disinfected. Prevention state shouldbeheat-sterilized thatthey andnothigh- theU.S.considered semi-critical, Centers for DiseaseControl and mucousmembranes.contact Althoughdentalhandpiecesare bone, tissue,soft bloodstream, contact tissuebutcan orsterile Any Instrument: instrumentthatdoesnotpenetrate Semi-critical scalers,periodontal andscalpelblades. tissue. sterile normally Examplesincludesurgical instruments, bone, enterscontacts thebloodstream, into or contacts orother : Any Instrument tissue,Critical instrumentthatpenetrates soft Ltd., 2004:2155-2179. Volume III:Applications. Bristol, ofPhysics U.K.: Institute Publishing J,C, Jones editors. Handbookoflasertechnologyandapplications. H,Davies B.Moseley Biomedicallasersafety. Part D3.5in: Webb London www.mhra.gov.uk. SW85NQUnited Kingdom, Agency, 10-2Market products Regulatory Towers, ElmsLane, 1Nine practices. andHealthcare Medicines 2008.Contact: DB2008(03)April light source inmedical, systemsandLEDs surgical, dentalandaesthetic bulletin.Guidance onthe safeuseoflasers, Device intense MHRA (UK). Orlando, Florida 32826USA,www.laserinstitute.org. Drive, Suite 128, 13501Ingenuity ofAmerica, Laser Institute 2008.ISBN978-0-912035-90-1Contact: ofAmerica Laser Institute best practices CLSOs’ ofAmerica. Laser Institute inlasersafety. 1sted. www.iec.ch.Contact: A widerangeofpublicationsrelating to laseruseandsafety. Electrotechnical Commission (IEC). International Safety andHealthAdministration. www.osha.gov. Contact: ofLabor–Occupational 01-05-001-PUB 8-1.7).U.S. Department andhazardOSHA (USA).Guidelinesforlasersafety assessment(STD Florida 32826USA,www.laserinstitute.org Drive, Suite 128,Orlando, 13501Ingenuity ofAmerica, Institute Published Laser (LIA).Contact: ofAmerica by theLaserInstitute ANSI Z136.1–2007American nationalstandard forsafeuseoflasers. clinician iscomplying withnational, federal, orregional regulations: Further reading isrecommended inorder to ensure thatthe F U RTHER READING READING RTHER 39 39 39 38

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