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!"#$%&'()*)*($%"+,-&

#./$0.$&"01&.2/0/.

! Jan Tunr

Swedish Laser MedicalSociety

!"#$%&'()*)*($%"'+,

-)./*($%0"1&1$2$1#&)3&4)($%$.*&&156(*7&1$"85.6&*)&


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'/)0$$%#

O McGuff P E, Deterling R A Jr, Gottlieb L S. Tumoricidal effect of laser energy onexperimental and human malignant tumors. N Engl J Med. 1965; 273 (9): 490-492.

O McGuff P E, Deterling R A Jr, Gottlieb L S, Fahimi H D, Bushnell D, Roeber F. Effects OfLaser Radiation On Tumor Transplants. Fed Proc. 1965; 24: Suppl 14: 150-154.

O McGuff P E, Gottlieb L S, Katayama I, Levy C K. Comparative study of effects of laser and/or ionizing radiation therapy on experimental or human malignant tumors. Am JRoentgenol Radium Ther Nucl Med. 1966; 96 (3): 744-748.

O McGuff P E, Deterling R A Jr, Gottlieb L S. Laser radiation for metastatic malignantmelanoma. JAMA. 1966; 31; 195 (5): 393-394.

O McGuff P E. Laser radiation for basal cell carcinoma. Dermatologica. 1966; 133 (5):379-383.

O McGuff P E. Tumoricidal effect of laser radiation on malignant tumors. Int OphthalmolClin. 1966; 6 (2): 379-386.

Endre Mester with Adam and Andrew


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The historic rats

3$4%)5*(&)6&67%


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8$%9/0)2)4,&.)067#/)0

O Low Level Laser

O Therapeutic Laser

O Biostimulative laser

O Soft laser

O Cold laser

O

and many more

:)#*&7#$1&*,+$#

O (Helium Neon 632.8 nm)

O InGaAlP 630-700 nm

O GaAlAs 700-980 nm

O GaAs 904 nm


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')5$%-&;


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@)7A2$&A2/01*71/$#B

11

!"#$%&'()*+,*)-).&/

Magnitude ofeffect(mean mm on VAS)

LLLTregardless ofdose

Oral NSAIDpublished data

LLLT optimaldose andtreatmentprocedure

Oral NSAIDafter correctionfor patientselection bias

Low BackPain

11 12 14(only 1 trial with

VAS data )

9

Tendinopathies

13 6 19 6

Neck Pain 23 - 25 -

Osteoarthritis 16 10 22 7

Median 13 10 19 7

Bjordal 2009


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!)#*&/0&*($&1)#"4$&C7042$B

The dose/fluence

Lost in the dosage

jungle?

@)#$

O Joule = energy notdose!

O Joule/cm2 = dose


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D0$%4,&+$%&E+)/0*EF

" ..is not a dose! But" ..is a practical and easily understood clinical

expression of the energy"Not to be used in scientific studies"A point is approximatively 5 mm2

G)72$&"01&1)#$Light green = 1 cm2

0.25 cm2

1 cm

1 cm


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H++2/$1&$0$%4,&I&;&G)72$

O Size of the laser aperture (in contact with tissue) = 0.25 cm2

O Dose: 1 Joule = 1 = 4 J/cm2

O area 0.25 cm2 0.25

J%%"1/"*/)0&6%)9/4(*&1/#*"0.$

Circle area = 1 cm2


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H++2/$1&$0$%4,&I&;&G)72$

O Dose:

O 1 Joule = 1 = 1 J/cm2O Area: 1 cm2 1

8,+/."2&K"H#&1/)1$/L$

O Diode area 1 mm2

Dose: 100 J/cm2

Energy: J Joule


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Randomized placebo-controlled LLLT trials in

chemotherapy-induced oral mucositis in children

No prophylactic effects on LLLT on mucositis severity and duration

Cruz et al.

780 nm, 60 mW, 4 J/cm2. But what was the irradiation time and energy dose ?

3 seconds

0.18 Joules

Toosm

alldoseto

induce

anti-in

flammatory

effect

s


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01)2"3)'&%.*4%$(+4/

0 4 8 11 15

Dose in Joules/cm2

Fibroblast inhibition

Fibroblast stimulation

Anti-inflammatory

Overlapping dose-intervals

Bjordal 2009

http://www.walt.nu


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K)21$0&%72$-Tissue regeneration: Low

output, long time

Antiinflammatory effect:

Medium output, long time


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Soft laserLow level laserLow intensity level laserLow power laserLow energy laserand others

Names in use

Suggested:

THERAPEUTIC

LASER


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Names in useLaser therapy

Low level laser therapy

Low intensity level therapy

Low power therapy

Low energy laser therapy

and others

MeSH term:

Laser Therapy, Low-LevelTreatment using irradiation with light at low powerintensities and with wavelengths in the range

540nm-830nm. The effects are thought to be mediated bya photochemical reaction that alters CELL MEMBRANEPERMEABILITY, leading to increased mRNA synthesis andCELL PROLIFERATION. The effects are not due to heat, asin LASER SURGERY. Low-level laser therapy has been usedin general medicine, veterinary medicine, and dentistry fora wide variety of conditions, but most frequently for wound

healing and pain control.Year introduced: 2002


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Suggested

LASERPHOTOTHERAPY

(LPT)

Some lasers for LPT

KTP 554 nm (green)

HeNe 632.8 nm (red) InGaAlAsP 630-690 nm (red)

GaAlAs 700-980 nm (partly invisible)

GaAs 904/905 nm (invisible)

Nd:YAG 1064 nm (invisble)


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Penetration & safety


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Courtesy: Aldo Brugnera Jr


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!

Penetration of laser light

Laser therapy dosimetry

http://www.walt.nu


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1. HeNe/Indium (633-770 nm)

2. GaAs (904 nm)

3. GaAlAs (780-830)

GaAs is different


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!"

Power output and dose

!"

Wavelength dependency


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Dose at TARGET


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Eye protection

Ivandic B T, Ivandic T.Low-Level Laser TherapyImproves Vision inPatients with Age-RelatedMacular Degeneration.Photomed Laser Surg.2008; 2 (3): 241-245.


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Stye on day of treatment with HeNe laser

The following day


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Green laser?

!!

!"#$%&'$#(%&)*+,%-'.$#%-'/-#(0


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!"

!"

!"#$%&'&$%"(#))*+&,-&!.&/01#2+&345#".67%#2&8#68%"9

:50+0;&?%#6&@%6*#$0A6B&CD8%


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!"

!"#$%&'(%'##)*%(+%,#-#%./0%./%1$$.01.2(/%3$#.)%(+%(/#%'##)4%%567*%8(/2/7#0%

1$$.01.2(/%.&%9:%;!'%,.%4&)1%06=!"+%!%T4/46!#5!#.)#)$,!(/6!;%!)*V/&%$!;6!+)2+!!#'!0#!??!$%!,*&.:0!.,!(1#!*9($!5556!)0.:2';!U-.G*-!1#*-(1!'(*(:'!$?20.+!,.0!?.0#!2*($#%('!$%!(1#!*9($!5556!)0.:2';!5./!-#-!-*'#0!(1#0*23!/$(1!(1#!':))#'(#+!+.'#!0*%)#!'$)%$=9*%(-3!0#+:9#'!2*$%!*%+!$?20.'!1#*-(1!'(*(:'!$%!910.%$9!8.$%(!+$'.0+#0'@!G:(!(1#!1#(#0.)#%#$(3!$%!2*($#%(!'*?2-#'@!(0#*(?#%(!20.9#+:0#'!*%+!(0$*-!+#'$)%!9*--'!,.0!9*:($.:'!$%(#020#(*($.%!.,!(1#!0#':-(';!


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Bjordal et al. BMC Musc Med & Eur J Pain 2007

Interventions for knee osteoarthritis

0

7,50

15,00

22,50

30,00

Lase

r

TENS

Electro

-aku

punctur

e

Stati

cmag

nets

Manu

alac

upun

cture

NSAID

oral

NSAID

gel

Steroid

inj.

Opioi

ds

Paracetam

ol

Gluc

osam

in

Chon

droitin

Pain relieving effect over placebo after 4 weeks

PainreductioninmmonVAS

!"#$


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!"#$"%"&'(&)*+"&)(&,"-*..*&/&0.&"12&30450&1"607&*8:7*:7+6."11980&"7.;7*$".;9062&&98S"##".9*8&*8:7*:7+6."11980&"7.;7*$".;906I&

0T$079#08."1&"8>&:1989:"1&[email protected]&M;*.*#0>&="607&?@7A2&BCCPE&BO&GBHI&FOC4FQC2

Pulsing


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820

n

m

Author Yea

r

Model Function Results

2.5 Salah O. El

Sayed

199

6

Animal Trophic Positive

4.5 Karu 199

8

In vitro Chemolumi

n.

Positive

10 Karu 199

9

In vitro Celladhesi/

trophic

Positive

20 Salah O. El

Sayed

199

6


16 Walsh 199

2

Animal Nerve.Cond

uction

Negative

Baxter 199 Human Antialgic Positive

73 Walsh 199

2

Animal Nerve.cond

uction

Negative

292 Salah O. El

Sayed

199

6


500

0

Walsh 199

2

Animal Nerve.Cond

uction

Positive

Bolton 199 Fibroblast Trophic Positive

200

0

Salah O. El

Sayed

199

6


890

n

m

Author Year Model Function Results

270 Lowe 1998 Animal Trophic Negative

666 Zharov 1987 In vitro/ E.

Coli

Trophic Positive

300

0

Yu,Chelysh

ev

1995 Animal

nerve

Trophic Positive

320

0

Yu,Chelysh

ev

1995 Animal

nerve

Trophic Positive

348

0

Zharov 1987 In vitro/

bacteri

a

Trophic (-)/

Inhib

(+)

Dose

depen

dent


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904

n

m

Author Ye

ar

Model Function Results

4 Ponnudari 1987

Human Analgesic Positive

5 Kucerov 1998

Animal Trophic(inmunosup)

Negative

10 Tam 199

9


60 Ponnudari 1987


67 Karu 1998

In vitro Ascorbicacidabsorption

Positive

Labbe 1991

In vitro Ascorbicacidconsumption

Positive

73 Lundeberg 1987

Human Analgesic Negative

Lam 1987

Humanfibroblast

Trophic Positive

80 Kapinosov 1996

Animal Stimulator Positive

100 Lievens 1989

Human Stimulator Positive

200 Ponnudari 1987

Human Analgesic Negative

830 Lucas 200

0

Human Trophic Negative

900 Nissan,

Rochki

nd

199

5

Animal

nerve

Trophic Poor

1000 Willner 198 Human Analgesic Positive

Lievens 198 Human Phisic Positive

1024 Shiroto 198

9

Human

blood

Stimulation

of

phagoc

ytes

Poor

1200 Dyson 198

5/

6

Animal Trophic Negative

1500 Longo 198 Animal Trophic Positive

Willner 198

5/

7

Human Antialgic Positive

Kapinosov 199 Animal Trophic Positive

2500 Molina

Soto/

Molero

198

7

Human Antinflamm

atory

Positive

3000 Longo 198 Animal Trophic Negative

Kapinosov 199 Animal Inhibitive Positive

3040 Mezawa 198 Animal Analgesic Positive


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4000 England 198 Human Analgesic Positive

4500 Nissanl 1995

Animalnerve

Trophic Poor

5000 Vlez 1988

Animalnerv

Trophic Positive

Molina

Soto/Molero

198

7

Human Antinflamm

atory

Positive

Lievens 1989

Human Deepstimu-lation,lymphatic

Positive

5120 Tam 199 Human Analgesic Positive

9000 Kucerov 199 Animal Trophic Positive

1000 Houghton 199 Animal Trophic Positive0

Meersman 199 Human Antialgic Positive

Lievens 198

9

Human Deepstimul

ation,lymphatic

Positive

Hashmi JT, Huang YY, Sharma SK,Kurup DB, De Taboada L, Carroll JD,


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! First official scientificevaluation of acupuncture

Acupuncture: Review and analysis ofreports on controlled trials.

293 studies


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! Certain types of pain

! Nausea and vomiting

! Throat problems

! Nocturnal uresis

! Any wavelength?! Any dosage?

! Any fibre size?

! Any pathological condition?

! Auriculotherapy?


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The laser-needles are pushed through a small one way tube of medical cardboard or

sterile stainless steel tube and are fixed at the acupuncture point with a small piece ofperforated tape.


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Fixing the laser-needles on the head and ear

Body acupuncture with laser-needles


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Acupuncture treatment of coxarthrosis

Ankle joint distorsion


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Cosmetic Acupuncture with laserneedles


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Coherence

! Light is not coherent or incoherent ! it is more or less coherent

! HeNe (from tube) can have a

coherence length of several metres

1

2


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Laser speckles

3

4

Real speckles on a photo


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5

Decreased length of

coherence

6

Hodes hamburger


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7

Laser vs. LED and flash lamp

Polarisation

! Laser light is not very polarised

but can easily be made polarised! Higher degree of polarisation is

advantageous (Bolton 1992, Nicola 1994)! But polarisation is lost shortly

after entering tissue (acc. to typeof tissue)

! Coherence is not lost

8


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Length of coherence

! Gas lasers like HeNe has very longlength of coherence from tube

! The length is considerably reduced inthe fibres

! Laser diodes of the same wavelengthas a gas laser have much shorter

length of coherence

Polarisation

! HeNe laser can be made polarised, but is

usually not! Diode lasers are partially polarised


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Laser, LED and light bulbs

11

Diode spectra

12


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13

LED - Light Emitting

Diodes

less monochromatic

non-coherent

lower output per diode

less expensive

less research published

but much improved in recent years

when compared in in vivo research,laser has a better effect so far

Laser/LED combination probes

! Are there any contra-productiveeffects when combining 2-6wavelengths in one unit?

! How do we know which wavelength/wavelengths are actually effective?

14


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LED instruments and the FDA

instrument to provideinfrared light therapy toprovide topical heating forthe purpose of elevating

15

16

LED - conclusions

LED therapy does work, but...

LED therapy is not yet as welldocumented as lasers, butdocumentation is improving

LLLT has so far been provensuperior shoulder-by-shoulder

LLLT and LED should probably notbe combined in the same instrument(exception: bleaching arrays)


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1

Laser therapy ofsomatosensory tinnitus

Jan Tunr DDS

Swedish Laser-Medical Societywww.laser.nu

2

Tullberg M, Ernberg M Long-term effect ontinnitus by treatment of temporomandibulardisorders: a two-year follow-up byquestionnaire. Tullberg M, Ernberg M. Acta

Odontol Scand. 2006 Apr;64(2):89-96.

The results of this study showed that

TMD symptoms and signs are frequentin patients with tinnitus and that TMD

treatment has a good effect on tinnitusin a long-term perspective, especially

in patients with fluctuating tinnitus.


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3

Mnires disease

! 1. Vertigo! 2. Fluctuating hearing loss! 3. And, sometimes, tinnitus

4

Tinnitus therapy

! Treatment of Meniere patients and solitarytinnitus patients is rather similar.

! In the following I will only speak abouttinnitus

! However, the following therapy is more

efficient for Meniere than for tinnitus


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5

Some suggested tinnitus

mechanisms! - Cochlear dysfunction (acoustic trauma,

violence)

! - Brain damage

! - Muscular tension (somatosensory tinnitus)

6

Lockwood AH, Salvi RJ, Burkard RF, Galantowicz PJ, CoadML, Wack DS. Neuroanatomy of tinnitus.Scand Audiol Suppl. 1999;51:47-52.

! We conclude that tinnitus is not

cochlear in origin and associated withplastic transformations of the central

auditory system. We suggest thattinnitus arises as a consequence ofthese aberrant new pathways and maybe the auditory system analogue to

phantom limb sensations in amputees.


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7

Somatosensory tinnitus

! Shore S E, Wyss N L, Altschuler R A.Trigeminal ganglion innervates the auditorybrainstem. J Comparative Neurology. 2000;419: 271-285.

! A connection between the sensory n.trigeminus and the ventral auditory nucleus inthe brain stem.

8

Bjorne A, Berven A, Agerberg G. Cervical signs andsymptoms in patients with Menieres disease: acontrolled study. J Cranomandib Practice. 1998; 16

(3): 194-202

! Bernhardt O, Gesch D, Schwan C et al. Signs oftemporomandibular disorders in tinnitus patients andin a population-based group of volunteers: results ofthe study of health in Pomerania. J Oral Rehab. 2004;31: 311-319.


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9

The acoustic pathways

Courtesy: Assar Bjorne

10

Differential diagnosis!

!

Can the patient change the character of thetinnitus through jaw or neck movements?

! Is the sound constant or changing?

! Are there signs of clenching/bruxing?

! Head/neck inclination? Posture?

! Tender points in muscles?


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11

Head, neck and jaw movements


13

Who is going to treat?

! The ENT doctor is generally not aware

of the dental connection! The dentist does not think this has any

dental background! The physiotherapist knows litte about

tinnitus! The patient does not think the dentist

can do anything about it and will nottell


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14

What do the ENT doctors, thedentists and the physiotherapists

15

Answer:

The broadband cable of the head andits sensory part


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16

Therapeutic alternatives

! Information (awareness)

! Occlusal adjustment (grinding)

! Laser therapy

! Physiotherapy

! Bite splint (in some cases)

17

Before therapy: stopp allanalgesic pill consumption


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18

Head and neck posture

19

Vulture neck


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20

Laser parameters

! - Infrared, preferrably above 100 mW

! - 6-10 Joules per point in contact

! - 2-4 Joules over TMJ

21

Why laser?

! Increases impaired microcirculation

! Reduces pain! Induces muscular relaxation

! Increases neck ROM

! Therefore, conventional therapies

become faster


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22

Principally involved muscles

! Masticatory (m. pterygoideus lateralis!)

! Suboccipital muscles

! Sternocleidomastoideus

! Upper trapezius

23

Typical pain areas



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26

With tinnitus

Bite splint notinnitus

27


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28

M. pterygoideus lateralis

Courtesy: Marie Tullberg

29


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30

M. digastricus posterior

32

Hard IP contacts in the front


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33

During occlusion the jaw isforced backwards

34

The condyle is pressedbackwards

! M. pterygoideus lateralis tries to pull the jaw forwardto avoid painful contact with the bottom of thefossa.

! Is the muscle causing the tinnitus sound or is there a

compressed nerve causing it, due to oedema in thejoint?



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39

K.N. - 38

! Tinnitus and headachestarted the same day asthe new crowns werecemented

! The crowns wereadjusted three days later

! Laser therapy and furtherocclusal adjustment were

performed, but it took 3months for the tinnitusto disappear.


40

The laser tinnitus literature

! Mostly available on alleged cochlear

dysfunction, 16 studies.! - very low to very high doses

! - different irradiation procedures

! - continuous or pulsed

! - combined with ginko biloba


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Surgical or therapeutical laser?

Or both?

Carbonisation

Vaporisation

Laser tissue interaction

Coagulation

Laser beam

Denaturation

Photothermic efect

Stimulating efect

HLLT

LLLT


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Near and far away

Power density

Power densities


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Energy per pulse

x

Pulses per secondX

Seconds

=

Energy

Energy per pulse

x

Pulses per secondx

seconds

./.

irradiated area

=Dose


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Er:YAG (2940 nm)

Zeredo J L, Sasaki K M, Fujiyama R et al. Effects of low power Er:YAGlaser on the tooth pulp-evoked jaw-opening reflex. Lasers in Surgery and

Medicine. 2003; 33 (3):169-172.

Zeredo JL, Sasaki KM, Takeuchi Y, Toda K. Antinociceptive effect ofEr:YAG laser irradiation in the orofacial formalin test. Brain Res. 2005 Jan25;1032 (1-2): 149-153.

Pourzarandian A, Watanabe H, Ruwanpura SM, Aoki A, Ishikawa Effect oflow-level Er:YAG laser irradiation on cultured human gingival fibroblasts. JPeriodo

ntol. 2005; 76 (2): 187-193.

Pourzarandian A, Watanabe H, Ruwanpura SM, Aoki A, Noguchi K,Ishikawa I. Er:YAG laser irradiation increases prostaglandin E2 productionvia the induction of cyclooxygenase-2 mRNA in human gingivalfibroblasts. J Periodontal Res. 2005; 40 (2): 182-186.

Conclusions

!1. Different wavelengths have different

biological effects but all can be used in therapy

!2. Surgical lasers are always biostimulating

!3. Through a change in power settings surgical

lasers can be used as primary biostimulators


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Two sides of the same coin

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