Forums › Laser Treatment Tips and Techniques › Soft Tissue Procedures › paraneoplastic pemphigus
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jetsfanSpectatorPatient was referred to me by oncologist. I will attempt to post more photos.
Patient living on narcotics for over 1 year due to mouth ulcers. As patient has very limited opening all I hope to accomplish on a first visit was to treat lips and commisures at .25W 0W 11A. My goal was to try to give some relief so that he will be able to open wider for next visit.
I have no idea how many visits this will take. I would like suggestions as to what type of spacing between appointments. How often should same are be retreated. And what about the tongue. I don’t know if I poste dthe photo but his tongue is denuded. It it shiny and red with no papillae.
Iwill keep you all posted on this one.
jetsfanSpectator
Last time.
You can see limited opening. Ulcers on lips , palate. Tongue photo was too large to post.
jetsfanSpectator
Here is one after right commisure treated. Photros are too large to load. I will try to make them smaller. I have a post op where he seems to have a slight improvement in opening. Patient returning tomorrow for treatment #2.
Robert Gregg DDSSpectatorHi jetsfan,
I’d select a pulsed Nd:YAG or 810 or 980nm diode. 2-3 watts (20 Hz) 20 to 30 minutes extra and intra orally once per day until gone.
Erbium is too superficial to get down deep where the light needs to be, but it could provide some relief.
Heck, even a red laser pointer would help her at home!
Bob
jetsfanSpectatorRobert,
I am not familiar with the use of Nd Yag or diode, does the area being treated need to be anesthetized .
marc andre gagnonSpectatorhi
If you want use diode 980 you can choose continuous mode at 1 watt with a fiber of 600um at least.
You sweap the lesion from outside to the center .
If you have a 1000um fiber you can do it at 1 or 2 watts continuous mode during 120 seconds on each spot.
You don’t have to use anesthesic because with low level the patient feel nothing more that little heat.
You can repeat when the patient feel that he gonna have a new lesion comming.
Robert Gregg DDSSpectatorjetsfan,
No anesthetic. You want the patient’s feedback as to whether it is getting to warm, then back off a little bit.
Marc Andre’s setting are appropriate for CW/gated 980 diode.
In my experience, it takes a while to cover an area this large and involved, especially with limited mouth opening.
And I was NOT kidding about your patient using a ษ red (670nm) diode laser pointer for relief and biostim–it will help her profoundly.
Bob
ericbornsteinSpectatorJetsfan:
I would question the diagnosis. With the lip lesions present, it is like no pemphigus that I have ever seen.
The presentation (with lip and tongue lesions) almost presents like drug induced Erythema Multiforme with a gingival component. Just a guess, but I would be careful until you had defintive Pathology and Microbial/Viral smears and plating, just to be sure what it is.
Good Luck.
Eric Bornstein DMD
ASISpectatorHi Jetsfan,
A smear biopsy is certainly the way to go with the Dx.
In addition to amlost daily laser therapy, whether it be diode or Erbium or Nd:YAG, how about daily plaque control along with some form of medicated rinses such as 0.12% Chlorehexidine or Tetracycline oral suspension.
The poor guy must be fairly inflamed. I can feel the soreness just looking at the photos. Is he hydrated sufficiently?
Good luck.
Andrew
jetsfanSpectatorEric,
The patient was referred to me by an oncologist who has the lymphoma under control. Patient has also been seen by dermatologists. I am confident with the diagnosis. In fact this is the second patient that I have had with exactly the same presentation and diagnoses.
Thsu far treatment with the waterlase has been remarkable. The first patient that says she has been in pain for 10 years. No one has been able to palliate her mouth symptoms. She has been on steroids, narcotics rinses you name it. She was referred to me by her oncologist who happens to be a patient of mine. Out of desperation she thought of me and the laser. Fortunately for her(the patient) it worked. I saw her today(third visit) and she basically happily fired me as she has no more pain. She will see me again if and when the need arises.
Patient 2, I also saw today. He is the one in the previous photos. Today was his 2nd visit. He has been on narcotics every day for over a year. The man has pain! If you notice (i admit it is difficult to tell) by photos he was able to open perhaps 2mm more at end of visit.
Today he reported he has much less pain. He is able to eat. I was able to treat right and left buccal mucosa. Last time I would not have been able to get handpiece in his mouth. By the time we finished today , he said pain was further reduced and he was able to open an additional 2mm.
So far so good. I’ll try to post more photos of both patients when I get time. Perhaps thursday.Robert . That red ษ laser . Where do I get them.
jetsfanSpectatorfollow up on the two PNP patients:
First woman treated over 1 month ago with waterlase at .25 W 0W 11A and had instant relief . After 3 visits she felt she didn’t need to see me again. I am curious to see how long the paaiative effects will last.
Patient two was the one whose photos were posted.
After first visit he had some relief and increased opening.
Perhaps it was a placebo effect because we have had five more treatments with no improvement. He does say it is easier to talk now but we have agreed to suspend further laser treatments.
Perhaps another , more penetrating ,wavelength would have helped him more.
Robert
Stewart RosenbergSpectatorI would tend to agree with Bob Gregg on this one. We usede to treat these types of lesions with a CO2 years ago and do a laser peel. Usually one or two visits were all that were needed. The Yags and diodes seemed to sometimes require less visits due to the deeper penetration of the laser energy with those wavelengths. The tradeoff waswith the C02 we can cover a wider area by defocussing and increasing the spot size.
I have not had an occasion to try an Erbium on one of these but I would suspect similar results to that of the C02 due to lack of penetration depth but it will take longer because of smaller spot size.
With the waterlase or an Erbium YAG maybe lasing, peeling and then lasing and peeling againonce or twice more at the same visit would compensate for the shallower depth of penetration. just a guess. no personal experience with the technique.
Stu
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