When we use the word dose in the DMC manual, you’ll notice that the word “energy” will be in parentheses. The dose we refer to is the amount of Joules (energy) deposited in the tissue. For example, we use between 0.5 and 2 Joules for soft tissue healing processes.
Creep, in turn, is the amount of energy deposited in a given area, which by convention is the area of the cross-section of the laser beam when we apply it in a timely manner. In the example cited above, the creep would be between 15 and 50 J/cm².
When we want to use laser therapy as a function of the patient’s characteristics, we need to reduce the dose or the fluency, because both parameters are interconnected. Decreasing the dose will automatically decrease the fluency. Similarly, the irradiation time will be decreased in the same proportion.
For ease of use and taking into account that the most prominent display on the equipment display is dose (J), you can use this parameter to adjust to the patient.
Low-level laser paresthesia treatment has the following objectives:
1. Accelerate nerve regeneration;
2. Stimulate contralateral innervation by causing adjacent nerves to play the role of the severed nerve;
3. Biomodulate the nerve response by bringing the action potential threshold to normal.
Since neuropathy exists, ie nerve cells tend to get used to certain stimuli, the treatment recommended by Nupen is to apply the dosage gradually. Initially we used a low dosage (1 to 2 J) per point in the first three sessions; in the next three sessions we use 2 to 3 J per point and in the other three sessions 3 to 4 J (1 J increases every 3 sessions). The decision to use the minimum or maximum doses described will depend on the time of the paresthesia (most recent intermediate doses, immunosuppressed patients, the elderly and children we use the lowest doses and the highest dosages we use for most patients, normal adults.
To calculate the application time just select on your equipment the dosage to be used in J, it will give you the application time punctual. It is important to remember that we use the spot irradiation mode by touching the equipment to the target tissue. In addition, it is important to take note of the patient’s improvement, asking each patient the percentage of improvement and different sensations experienced such as needling, tingling and even pain. In the latter case it is recommended to decrease the dosage. The first two reported symptoms usually indicate positive evolution. The frequency of application may be every 48 hours (fastest results), every 72 hours or once a week, depending on your patient’s availability.
Herpetic lesions have 3 distinct stages of manifestation and we must identify them clinically before using laser therapy correctly. The following is a description of the 3 phases and the recommended dosimetry.
– Prodromal Phase: Itching, heat and redness in the region. The manifestation is observed in the face of hormonal variations (menstrual phase), situations of stress, emotional shaking, low immune resistance (colds for example) and excessive exposure to the sun.
DOSIMETRY: infrared laser with the dose of 3 J at 2 or 3 points in the region.
– Vesicle Phase (small vesicles, pain and swelling in the region): In this phase the herpes virus can be transmitted by direct contact with the vesicular fluid. Self-contamination in other parts of the body should be avoided, using towels and individual dishes until the end of this phase.
DOSIMETRY: Almeida-Lopes technique of drainage through laser irradiation over the lymphatic chain responsible for the affected region and around the lesion. The laser used is infrared with the dose of 3 J.
– Lesion healing phase (crust phase): In this phase the patient no longer reports pain, but uncomfortable with the wound that takes a long time to heal completely.
DOSIMETRY: Red laser dose of 1 J, 2 J or 3 J points on the lesion depending on the extent of the lesion, daily until complete healing.
Laser therapy in dentin hypersensitivity acts in two ways:
1. Promoting immediate analgesia, reported by the patient immediately after application;
2. Stimulating the formation of reparative dentin in the medium and long term.
Before starting laser therapy it is recommended to check the cause of hypersensitivity. Among the most common are: root scraping, tenderness after routine occlusal adjustment, exposure of dentinal tubules and cutting of odontoblastic extensions after a cavity preparation, gingival retraction (due to excessive brushing force, bruxism, excessive acid feeding, etc.), among others. .
Protocol for immediate analgesia: Application should always be with the laser tip perpendicular to the tooth or apical region. Infrared laser at doses of 3 J is preferably used when a single application is chosen as a treatment, for example in post-whitening hypersensitivity. According to the patient the clinician may choose one of the therapeutic modalities proposed below:
1: The application can be made 2 points per tooth: one point in the cervical and another in the apical region of the tooth, dose of 3 J per point (indicated for molars);
2: Apply 2 stitches on the cervical (one buccal / palatal / lingual) and one stitch on the apical region, 2 J dose per spot (robust teeth with many restorations);
3: Apply 1 point to the cervical or apical area at a dose of 2 J per point (indicated for uniradicular teeth, in situations where several teeth are affected, or in case of pain after orthodontic activation).
Protocol for the production of reparative dentin (medium-term analgesia): The application should be done with the laser tip always perpendicular to the tooth or apical region. Preferably the red laser at doses between 1 and 2 J per point is used. According to the patient the clinician may choose one of the therapeutic modalities proposed below:
Immediate local analgesia may be the clinical parameter that indicates that the dosimetry for that patient is correct. Therefore, if the patient does not report immediate analgesia after the first irradiation, you may be repeating the application. But keep in mind that excessive repetition can inhibit reparative dentin biostimulation processes, despite causing immediate analgesia. Therefore caution is advised. Repeat only twice, and explain to the patient that the effect will come in the medium to long term.
1: The application can be made 2 points per tooth: one point in the cervical and another in the apical region of the tooth, dose of 1 J per point (indicated for molars);
2: Apply 2 stitches to the cervical (one buccal / palatal / lingual) and one stitch to the apical region, 1 J dose per spot (robust teeth with many restorations);
3: Apply 1 point to the cervical or apical area at a dose of 2 J per point (indicated for uniradicular teeth, in situations where several teeth are affected, or in case of pain after orthodontic activation).
Repeat this protocol every 72 hours for two weeks. That is: twice a week for two weeks.
The low power laser lymphatic drainage technique, developed and published by Profa. Dr. Luciana Almeida-Lopes, consists of laser irradiation in the main lymph node chains responsible for the drainage of the head and neck. The objective is to reduce edema in the postoperative period, postoperative dental procedures, herpetic vesicles, etc .; by activating the lymphatic drainage of the region affected by this edema.
Protocol: 2 points applied to each lymph node chain – preauricular, jugulo-digastric, submandibular and submental – on the affected side (right and / or left), with infrared laser and doses between 2 J and 3 J of energy per point). The frequency of application may vary from 2 to 3 times a week until regional edema is reduced.
The LED and laser light sources used for tooth whitening are directed to the patient’s mouth, not being able to penetrate or reach the uterine region of the operator. The laser light emitted from the equipment has a capacity to penetrate the oral tissues around 1 cm. Thus, they are not spread on the patient’s body or in the environment.
Therefore, pregnant professionals can perform the whitening being careful not to direct the lights to the abdominal region directly in the first trimester of pregnancy.
The low power laser acts on oral mucositis as a local anti-inflammatory, analgesic and healing agent, helping to heal oral lesions and improving the patient’s salivary flow, in addition to activating the patient’s local immunity.
For the patient, this means higher quality of life, since patients with Oral Mucositis have great difficulty in eating, swallowing and cleaning the oral cavity. In this sense, guaranteeing the patient the possibility of being able to eat properly, improves his general condition, fundamental for the success of the medical treatment in which he is.
There are currently preventive protocols, to be previously applied is the installation of mucositis and there are protocols for already established mucositis.
Protocol (preventive treatment):
1- Preventive Treatment: Begin treatment along with chemo / radiotherapy sessions. It is a preventive treatment since the formation of mucositis is not expected on the 4th or 5th day of antineoplastic treatment. The objective is to prevent lesions from appearing or to decrease their intensity. Applications can be daily (5 x per week) or according to patient availability.
2- Regions of application: Application should be in the 8 regions described below and the number of points in each will depend on the energy density applied: right and left jugal mucosa, palate, lower lip, upper lip, lingual and lateral dorsum. of the tongue and buccal floor. Irradiation should not be performed on the biopsy site or where the tumor lesion was located and a safety margin should be given for laser application 2 cm away from the lesion site. In patients with swallowing pain, extraoral application to the neck may be performed except in patients with a tumor in this region.
Energy per point: about 1 J per point
Number of Points: Apply 3 Points per Region
PROTOCOL (clinical mucositis):
1- Treatment of installed mucositis: Daily applications or according to patient availability until completion of chemotherapy or radiotherapy. Some clinicians continue this application for a few more days.
* If the mucositis is quite intense or covers a large area, give preference to the lowest dose applying at more points.
The objective of laser irradiation for xerostomia treatment is to stimulate the glands to perform their normal function (or close to normal) even in adverse situations, such as radiotherapy, Sjögren’s Syndrome and the use of some medications, which promote changes in this tissue.
The laser therapy protocol for xerostomia cases is:
• Infrared laser;
• Energy density: 2 J, 100 mW, continuous mode;
• Perform 2 points in each region corresponding to the location of the major salivary glands: sublingual, submandibular and parotid;
• 48/48 h or 72/72 h applications.
Frequency and duration of treatment: sessions can be held for 48/48 hours or 72/72 hours with a minimum of 5 sessions. If the case is a xerostomia caused by radiotherapy, it is ideal that the laser therapy is performed while the patient is undergoing radiotherapy characterizing the preventive treatment of the laser. In this case the applications may be daily or according to the frequency of radiotherapy sessions until the end of the antineoplastic treatment.
Laser therapy applied to TMJ dysfunctions has analgesic, anti-inflammatory, muscle relaxant action and assists in the repair of traumatized nerve fibers. Patients with trismus (of mixed origin) or on TMD treatment are indicated for treatment with laser therapy.
The laser application should be done at 5 points over the joint region: 1 point over the condyle, 3 points: one 1 cm ahead, another 1 cm above and another 1 cm below the condyle and the fifth point inside the condyle. outer ear towards the condyle. Also, if there is muscle pain, chewing-related muscles should be palpated and pain points (trigger points) should be irradiated.
The recommended energy per point is 3 J.
Irradiation at both TMJs is recommended using the infrared (invisible) laser, with applications every 72 hours while symptoms persist.
The use of laser does not eliminate the need for oral rehabilitation if patients need more complex treatment. The ideal is therefore to associate the conventional technique (myorelaxing plates, occlusal adjustment, etc.) with the laser.
The laser application protocol foresees the previous cleaning and drying of the surface (intra or extraoral). This improves laser penetration due to less light reflection, which happens to a greater degree when the surface contains water (water reflects more light). If the surface is not dry, this will not prevent the therapeutic action of the laser. What can happen is that the laser reaches the lowest depth of tissue penetration. This lower penetration also occurs when we employ lower powers. The lower the power used, the lower the laser penetration in the tissues.
Traumatic ulcer is a painful lesion characterized by a central ulceration area covered by a fibrin pseudomembrane, necrotic tissue remnants and microorganism aggregates, surrounded by an erythematous halo. Usually disappear between 10 and 21 days without leaving a scar. Laser therapy can be performed to accelerate ulcer healing as well as to relieve painful symptoms. In ulcers without painful symptoms, the indicated dose is: Red Laser, 1 J energy, 2 points, immediately after the appearance of the lesion and every 24 h. In ulcers with painful symptomatology, the previous dose may be repeated 3-4 times (according to the patient’s clinical report on pain). Usually 2 to 4 clinical sessions are held for the treatment of traumatic ulcers. Relief of painful symptomatology will determine the termination of treatment.
Trigeminal neuralgia is characterized by dysfunction of the trigeminal nerve (cranial nerve V), which carries information on the sensitivity of the face to the brain. Its dysfunction causes episodes of severe and stinging pain lasting from a few seconds to minutes.
Neuralgia has two forms: idiopathic – of unknown origin and usually chronic and secondary – usually caused by trauma of dental origin, such as extraction, endodontic treatment or even poorly adapted prosthesis. Regardless of the type of neuralgia, this type of involvement is usually refractory to conventional treatments and laser treatment is a clinically very effective option and is still a noninvasive technique with no side effects.
The diagnosis is made based on the patient’s report along with their clinical history, seeking to map the possible causes and symptoms. Aspects such as pain triggering factors should be considered (eg cold, chewing, ice water, etc.). Next, we seek to find out which branch of the nerve is affected from the region whose patient has painful symptoms. Trigger points are not always easily detected in these cases, but they are the points of intense pain that the patient can identify.
Laser therapy acts to promote analgesia by healing of injured nerve fiber or recovery of altered nerve threshold.
The beneficial action of the laser is associated with its local anti-inflammatory and analgesic effect by modulating nerve beam dysfunction (which is what characterizes the disease). The nerve transmission threshold returns to normal and the painful crises characteristic of neuralgia are avoided.
The application should be done along the path of the affected nerve, punctually, with a distance of 1 to 1.5 cm between the points with the following parameters:
– Laser at infrared wavelength (808 nm), energy density between 1 and 2 J. To avoid nerve neuroplasticity, where the optical fiber gets used to the stimulus, the irradiated dose should be changed every 4 sessions. about. Thus, the treatment should be started with a lower energy per point, gradually rising until reaching the maximum dose (which will be fixed when it reaches the tenth session). If the lesion persists, the reverse path should be taken, this time decreasing the dose by point gradually.
In general, there will be 10 to 20 sessions that can be done 2 to 3 times a week (being careful to give a minimum of 24 hours between one application and another).
Also, in order for the effects of the Laser to be significant, it is very important not to associate the treatment with CARBAMAZEPINE (TEGRETOL). If the patient is already using it, one should gradually reduce the medication.
The harmful effects that the laser can cause are limited to the eyes. The manifesting eye lesions vary according to the wavelength of the laser light. Red and infrared lasers used in phototherapy can cause the following effects:
Visible light from 400 to 780 nm (the red laser used has an approximate wavelength of 685 nm):
The retina suffers thermal and photochemical lesions as all other elements of the eyeball are transparent to these beams.
Infrared rays A, from 780 to 1,400 nm (the infrared laser used has an approximate wavelength of 830 nm):
These wavelengths are the most dangerous for the eye, which does not perceive the beams of this length, but focuses them on the retina, where they cause severe burns and photochemical lesions of the retina. In addition, some of these beams are absorbed by the lens, leading to turbidity, that is, cataract.
This means that we can never look directly at the laser beam and the use of goggles by the patient, operator and assistant is indispensable.
The values usually practiced for Laser Therapy and charged per application session, are usually calculated according to the clinical time of the professional in question (for each office and reality the dentist must make and adjust this calculation).
There is an important distinction for some types of treatment, which may be charged for packages. These are the cases of treatment of Paresthesias, Paralysis and TMD, Xerostomia and Mucositis. For virtually the laser is the treatment alone, and usually involves some clinical sessions (minimum 5 and maximum 20). The packages vary from region to region in Brazil, based on the average consultations practiced in each region of the country. Regarding the way to charge the other treatments, which associate the laser with the conventional treatment, such as cases of extraction, hypersensitivity, periodontics, for example, an increase of 15 to 20% in the total treatment value is usually calculated (with reference to values practiced in the dentist’s office in question).