Shining the light on laser safety: 4 steps to keep your practice compliant

What an exciting time to be practicing the art of dentistry. Never before has there been so much technology available to aid clinicians in the diagnosis and treatment of oral conditions. One of these newly embraced technologies is the laser-specifically the soft-tissue laser, which can be used for the management of periodontal infections.

Using a laser to decontaminate the periodontal pocket, in conjunction with scaling and root planing, has proven to be effective in managing early to moderate periodontal infections.¹ Consequently, dentists are seeking to hire dental hygienists and associate dentists who are educated about laser use, and both dental hygiene schools and dental schools are beginning to incorporate laser education into their curricula. Furthermore, registration for laser courses at dental meetings has to be done early because the courses fill up so quickly.

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One of the most important components of all laser education courses is laser safety education, compliant with the American National Standards Institute (ANSI) standards, ANSI Z136.1 "Safe Use of Lasers" (2014) and ANSI Z136.3 "Safe Use of Lasers in Health Care Facilities" (2014). Understanding and adhering to these guidelines will keep both patients and practitioners safe when lasers are used in the dental practice. Compliance with these regulations is extremely important but does not have to be complicated. Compliance can be broken down into four simple steps, so ANSI standards for laser safety can be implemented easily in every dental practice.

Know the standards

ANSI sets the general and clinical standards that define the requirements for the safe use of all types of lasers (Z136.1) and the safe use of lasers specific to health-care facilities (Z136.3). The Laser Institute of America (LIA) serves as the secretariat for the ANSI Laser Safety Committee and publishes the required laser standards and documents. Although ANSI provides laser safety recommendations, it does not have any regulatory powers to enforce these guidelines. The Occupational Safety and Health Administration (OSHA), however, has general authority to regulate workplace safety, and it relies on the recommendations described in ANSI Z136.1 and ANSI Z136.3. The objective of the standards is to provide reasonable and adequate guidance for the safe use of lasers in general and the safe use of lasers in health-care facilities such as dental offices.

The ANSI standards classify lasers and laser systems according to their relative hazards and specify appropriate controls for each classification (table 1).

Lasers used in dentistry for bacterial decontamination or ablation techniques are Class 4 lasers. Class 4 lasers are high-powered and can pose a hazard to the eye or skin from direct-beam exposure. ANSI Z136.3 defines key safety protocols to be followed to keep all laser operators, auxiliaries, and patients in the dental office safe.

Identify a laser safety officer

In compliance with ANSI Z136 standards, any facility where a Class 4 laser is in use requires a laser safety officer (LSO) to oversee the laser safety program. The LSO is the one person in each facility who has been trained in laser safety and is responsible for the laser safety program. The LSO's primary responsibility is to monitor the control of laser hazards and ensure compliance with the guidelines established by ANSI Z136.3. The LSO is accountable for ensuring that all team members, including front-office staff, have received the recommended training.

The LSO does not necessarily have to be a clinician; any team member can perform the duties with the required training. However, choosing a highly engaged team member is always best. Some states require that all Class 4 lasers and associated LSOs be registered with the state.

Arrange training for everyone in the office

Perhaps the most important consideration for the safe use of lasers in the dental office is appropriate training for clinicians and team members. Many organizations offer different levels of training for implementation of lasers in the dental practice, and many state boards specify training guidelines and proficiency levels, as well as organizations recognized to teach laser education. For clinicians seeking laser certification courses, programs that are didactic, hands-on, and device-specific are highly recommended. Online courses that do not allow for hands-on experience do not meet the standard of education necessary for clinicians to achieve basic proficiency in operating lasers.

Maintain a nominal hazard zone when lasers are in use

The nominal hazard zone (NHZ) is defined as the area where the level of direct, reflected, or scattered radiation poses a hazard to the skin and eyes during normal laser operation. Simply put, it is the area around the patient where proper safety protocols must be followed. The NHZ differs for all lasers and is dependent upon laser wavelength, laser fiber size, and beam divergence. Information relative to a laser's specific NHZ can be found in the manufacturer's laser manual or "Information for Use" guide. The NHZ should be restricted to only the patient and necessary personnel. For most lasers, the entire dental operatory becomes the NHZ. Within the NHZ, the following actions must be taken to comply with ANSI standards: (1) Appropriate laser safety eyewear must be worn by all; (2) proper signage must be posted on each NHZ entrance; (3) precautions must be taken to prevent fire hazards; and (4) laser plume must be managed.

All people within the NHZ must wear appropriate laser safety eyewear specific to the laser in use. Laser safety eyewear is labeled with its optical density and the wavelengths it will protect against.

Every entrance to the NHZ must also be marked with an appropriate sign. In January 2014, ANSI adopted an updated laser safety sign that is marked "warning" (figure 1). The sign also indicates the laser's classification, wavelength, and maximum power, as well as the required optical density for the laser safety eyewear (figure 1). The laser safety sign is typically provided by the laser manufacturer with purchase.

Figure 1: A laser safety sign must be displayed at each entrance to the nominal hazard zone.

Precautions must be taken to prevent potential fire hazards. Combustible materials, such as alcohol, should never come in contact with the working beam of the laser. If general anesthesia is administered with the use of a laser, noncombustible gases for general anesthesia must be used. Nitrous oxide can be used in conjunction with a laser as long as there is an appropriate scavenger system.

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Other safety considerations include the management of laser plumes. Laser plumes, also known as laser-generated air contaminants (LGACs), are a biological hazard consisting of visible or invisible gas fumes created when tissue is ablated or vaporized. Proper management of the laser plume is imperative as laser plume has the ability to carry viruses, bacteria, and other organisms that can be hazardous to the laser operator and assisting personnel. High-volume evacuation is required when the laser is in use, and surgical masks should be worn.

As with the adoption of any new technology, it is incumbent upon each clinician to seek education for proper use, safety, and compliance with state and national guidelines. A great way to get started is to check with the local state board for guidelines about laser education specific to that state. Clinicians can then take action with these four easy-to-implement steps to ensure their laser programs are safe, efficient, and productive.

References

1. Kamma JJ, Vasdekis VG, Romanos GE. The effect of diode laser (980 nm) treatment on aggressive periodontitis: evaluation of microbial and clinical parameters. Photomed Laser Surg. 2009;27(1):11-19.

Jan LeBeau, RDH, BS, has spent more than 30 years in the dental field, including 15 as a clinical dental hygienist. She now chairs the dental hygiene program for Pacific Dental Services®. Jan also serves as cochair of laser safety for the Academy of Laser Dentistry.

Editor's note: Previous versions of this article were originally published by the Academy of Laser Dentistry (ALD) in Lightwaves, Spring 2015; E-waves Member Update, Winter 2016; and the ALD Blog. It has been updated and republished with permission from the ALD.