Hi Janet……..use both lasers ( the diode works deeper and the erbium more superficial) and I would use the erbium first which is less sensitive and then go deeper but lets see what others suggest.

glenn

Hi Ron,

This is a GREAT question!

I know from where and whence the phrase “use the least amount of energy to reach the treatment objective”  came from.

It came from the early days of pulsed Nd:YAG clinical laser use (1990) where we had no idea of light dosimetry in tissues for anything.  So the idea was advanced that the “least” amount of energy to achieve what  we “thought” was the treatment objective was coined and advanced–chiefly by Professor Doctor Joel White at UCSF and his like-minded laser dentist colleagues in the ALD with Educator Status (which I have as well but don’t agree on this point).

For new laser users, this laser Rule of Thumb is a “nice” admonition…but not necessarily safe, accurate, efficient, nor optimally therapeutic.  Sure, you can see some “nice” results with that Rule of Thumb, but we can be more predictable and knowledgeable about the treatment results than that!

In order for that laser “Rule of Thumb” to apply, one needs to FIRST define what the Treatment Objective is.  

In herpetic lesions, the T.O. might be:

a.  ease the itching and pain
b.  reduce swelling
c.  reduce inflammation

OK STOP!  Then follow the protocol you used.

If you also want to:

d.  keep the itching, swelling, inflammation and pain from returning
e.  kill the maximum amount of live virus
f.  dentature pathologic proteins
g.  inactivate epithelial tags necessary for viral replication
h.  a. b. c.
i.   d. e. f. g. h. i
j  All the above
k.  None of the above

If “j” is your answer, then a new treatment protocol–and light and time intensity–is indicated…..

In our training we advocate that the treatment objective is to put the OPTIMAL, not the LEAST nor the MOST amount of energy to reach the treatment objective, such that no extended lateral tissue injury ocurrs.  Sometimes that means our powers are VERY high, but our tissue interactions times are very short.  Sometimes it means our treatment times are longer, and our energy and intensity are high, but our effects are diffuse, wide and deep.  Remember your hard tissue analgesia settings.

Herpetic lesions require a light intensity sufficient to have the live virus killed, the inflammatory proteins denatured, and the epithelial tags inactivated (so no new lesions recur in that same treatment site).

One more thought:

The light intensity (light dose) that you are able to put in using EMLA is actually MORE intense and “harmful” than a defocused application which uses more time and less energy to the surface and diffuses deeper into tissue (like you do when you use your erbiums to create analgesia in teeth by “painting” the tooth at 6 watts and at distance).

Also, local anesthetics penetrate skin and mucosa and enter the blood stream in high concentrations.  I’m not shy about using it, but for the sake of the “safety” arguement, there is a higher chance of anesthetic toxicity with topical versus local.  So I don’t see the safety aspect of using ELMA and close proximity irradiation from that aspect.

OK, how do you caluculate?  

By not using the ELMA and monitoring the patient’s response.  It takes about 30-60 seconds for the lesion to become numb for the patient, then another 3-4 minutes per centimeter to complete the treatment.  (Pssst! Knowing that your lasers create analgeisa in pulp tissue, why not try it for soft tissue boo boos?!)

It also helps to know the energy at the fiber tip and have a power meter and joule counter on the laser–but that would make it too easy!!:biggrin:

Thanks for the question!

Have a great weekend!

Bob

(Edited by Robert Gregg at 7:58 pm on Jan. 10, 2003)

Good Morning Ron,

Why do I feel like a fish being reeled in?

To answer your questions:

Measurements, histology, research, study, experience.

Yes.

Correct.

Ummm….correct.

(correct)

Right!

Absolutely.

By George, I think you’ve got it!

:biggrin:

Bob

Can I come back later and place the quotes where they belong for the answers?

Thanks to all for their posts.
This is a somewhat off subject question. What about using the delight or waterlase to remove some of those ‘age’ or ‘sun’ spots we seem to get the older we are? (This is not a question for tx of pts but of myself)?
Another question closer to topic. What is your relative fee for tx of apthous or herpes lesions?
Greg

Hi everyone. A first timer here.
How do you guys bill such tx, apthous or herpetic lesion, to the ins. ? Have you had any rejections ? Thanks

Lotsa great stuff on this thread. I’d just like to comment that I also use both the erbium and diode on both herpetic and apthous ulcer lesions. Different depths of penetration and surface effect.

They work wonders.

Rod

I posted this on DT (mainly because I enjoy the abuse) and thought I’d add it to this thread …

In the Standard Certification Course given by Hoya, we were introduced to treating RAU and herpetic lesions similarly, the only difference being that we were instructed to use viral-filtering masks when ablating herpes lesions to avoid inhaling the infected laser plume.

Another poster on DT questioned the wisdom of this procedure, fearing that we’re spreading viruses all over our offices without adequate protection for ourselves and our patients.

Got me thinking. Indeed, even if we use the high-volume vacuum to suck up the plume, where are the viruses going? Aren’t they being spread throughout our vacuum system? Can any un-sucked plume REALLY spread infection elsewhere in our offices, threatening other staff and patients?

Since laser treatments are in their infancy, nearly everything we do is in someway still being explored. Have we delved headlong into the techniques without considering the adjunctive ramifications of our treatment?

On the other hand, are these questions overboard? Is this a case of worrying about a problem that doesn’t exist? The last thing we need is knee-jerk overreaction to an unrealistic fear (can you say, “OSHA”?)

Knowing nothing about virology and even less about how viruses might be spread through the laser plume, I’m adding this in hopes that someone out there may possess authoritative knowledge about this topic and can offer some guidance.

Any takers?

— Don