4/7/2012. Disclosure. Introduction to Photobiomodulation. Dr. Gerry Ross, DDS. Presentation Outline. Tottenham, Ontario

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1 Disclosure Tottenham, Ontario Introduction to Photobiomodulation Dr. Gerry Ross, DDS Canada Dr. Gerry Ross is President of Laser Light Canada, a company focused on the education, training and distribution of Low Level Laser Therapy products. The company works with a variety of manufacturers, none of whom had any contribution to this presentation. No funding was received for this presentation. Presentation Outline Benefits of being a member: -Subscription to Photomedicine and Laser Surgery Journal includes access to all previous issues -Facebook Discussion Forums -Discounted registration to NAALT Conferences and events -Newsletter For more information and to register, members@naalt.org What is Laser Therapy? Primary and Secondary Effects of Laser Therapy Biphasic Dose Response Clinical Applications in Dentistry Low Level Laser Therapy (LLLT), also known as phototherapy or biostimulation, uses light energy in the form of photons from Low Level Lasers or Superluminous Diodes to elicit cellular and biological responses in the body. 1

2 Optical Window Where the effective tissue penetration of light is maximized Runs from approximately 600nm 1000nm Absorption Coeffiecient Wavelength (nm) Treatment Window Water Deoxyhemoglobin Oxyhemoglobin Cytochrome C oxidized Cytochrome C reduced M. Cope thesis data modified by M. Patterson Slide courtesy of Meditech International Increases ATP (cellular energy) Wound healing, Tissue Repair, Prevention of Tissue Death Generates Reactive Oxygen Species (ROS) Superoxide anion, H2O2 Stimulates cell signaling and gene transcription Relief of inflammation, Pain, Edema, Acute Injuries, Chronic Diseases Regulated by antioxidants within 1 hour NeurogenicPain, Neurological Problems, Acupuncture Cytochrome-c Oxidase Published Action Spectra Subunit of the mitochondrial electron transport chain Has absorption bands from nm centre Cu A red 620 nm Cu B oxid 680 nm Cu B red 760 nm Cu A oxid 820 nm Binds Red light Binds Infrared light Wavelength, nm Karu and Afanasyeva, DAN 392(5):693, 1995 Red light at 660nm and Infrared light at 830/840nm 2

3 Nitric Oxide Inhibits cellular respiration Binds to different places on cytochrome-c oxidase NIR and red light temporarily bumps NO off which increases cell respiration and ATP synthesis Reactive Oxygen Species (ROS) Produced in mitochondria Include oxygen ions, free radicals, peroxide Light generates small amounts ROS Generates Reactive Oxygen Species (ROS) Superoxide anion, H2O2 Regulated by antioxidants within 1 hour A little bit is good, a lot is bad Regulated by antioxidants Stimulate production of ATP Adenosine Triphosphate (ATP) Increases ATP (cellular energy) Generates Reactive Oxygen Species (ROS) Superoxide anion, H2O2 Regulated by antioxidants within 1 hour High energy molecule that fuels cell processes Produced by cellular respiration Used by enzymes and structural proteins in many cellular processes 3

4 Mitochondrial Mechanisms of Photobiomodulation Literature Review Mitochondrial Mechanisms of Photobiomodulation in Context of New Data about Multiple Roles of ATP Tiina Karu, Dr. Sci, PhD Photomedicine and Laser Surgery 2010 Increasing the amount of this energy may improve the cellular metabolism, especially in suppressed or otherwise ill cells. ATP is not only an energy currency inside cells, but it is also a critical signaling molecule that allows cells and tissues throughout the body to communicate with one another. Mitochondrial Mechanisms of Photobiomodulation First, chronic and neuropathic pains are the disorders treated successfully with LLLT for many years. ATP signaling is believed to be involved into pain therapy. Second, it is proposed that acupuncture (mechanical deformation of the skin by needles and application of heat or electrical current) leads to release of large amounts of ATP from keratinocytes, fibroblasts, and other cells in the skin. Acupuncture by laser light is a well-known modality. Third, the tumor-killing action of the photobiomodulation technique has been documented but met with skepticism. A tumor-killing effect of ATP has been described. Increases ATP (cellular energy) Generates Reactive Oxygen Species (ROS) Superoxide anion, H2O2 Stimulates cell signaling and gene transcription Regulated by antioxidants within 1 hour Cellular Effects MOLECULE BIOLOGICAL EFFECT CLINICAL BENEFITS Growth Factors TGF-β, PDGF, BDNF, IGF-1 Proliferation Differentiation Normal tissue regeneration Reduces scarring Rapid recovery Interleukins IL-1a, IL-6, IL-8, IL-2, IL-4 Inflammatory Cytokines PGE2, COX-2, IL-1β, INF-α Migration Immunological activation Inhibition of inflammation Resolves difficult infections Improves Inflammatory response Reduces pain and swelling Improves range of motion Functional recovery Increases ATP (cellular energy) Generates Reactive Oxygen Species (ROS) Superoxide anion, H2O2 Stimulates cell signaling and gene transcription Regulated by antioxidants within 1 hour Small Molecules ATP, cgmp, ROS, Ca2+, NO Angiogenesis Cell signaling Restores normal vasculature Resolves chronic ulcers Wound healing, Tissue Repair, Prevention of Tissue Death Relief of inflammation, Pain, Edema, Acute Injuries, Chronic Diseases NeurogenicPain, Neurological Problems, Acupuncture Slide courtesy of Meditech International 4

5 Secondary Clinical Effects Secondary Clinical Effects Lymphatic flow Reduced edema Collagen Synthesis in Fibroblasts Wound healing Stimulates production of β-endorphins (the bodies own natural pain-killer) Pain Relief Angiogenesis and Neovascularization Creation of blood and lymph vessels Reduction of depolarization C fibers (the fibers which carry pain impulses from teeth) DNA and RNA Synthesis Decreases pain sensation Protein Synthesis Stimulation of Osteoblasts Builds bone and And Odontoblasts dentin Decreases Histamine, Bradykinins, Decreases Substance P, Acetylcholine inflammation and pain Biphasic Dose Response Describes the dose-dependent effects of LLLT and is modeled by the Arndt-Schultz Curve If insufficient energy is applied, there will be no response (minimum threshold must be met) Weak or lower stimulus will result in biostimulation Higher amounts of stimulus will result in bioinhibition Arndt-Schultz Curve 5

6 4/7/2012 Post Extraction Reduction of post-op pain Reduction of post-op swelling Faster healing Reduced out of office calls making it a practice builder Dental Infections Application for Lymphatic Drainage Reduction of edema (swelling) Stimulates the immune system and brings neutraphils to site of infection for faster healing Submandibular Lymph Nodes Apply to Submandibular Lymph Nodes Using LED curing light, apply 20J (20sec) over area of infection Laser Application will not preclude use of antibiotics in most cases but will stimulate the effect of the antibiotic by stimulating lymphatic system Blue nm Light Kills MethicillinMethicillin-Resistant Staphylococcus aureus (MRSA) in Vitro Literature Review Photo-irradiation produced a significantly significant dosedependent reduction in both the number and the aggregate area of colonies formed by each strain of MRSA More than 90% of the colonies were killed with an energy density of 55J/cm² Blue nm Light Kills MethicillinMethicillinResistant Staphylococcus aureus (MRSA) in Vitro Chukuka Enwemeka et al Photomedicine and Laser Surgery 2009 Image courtesy of Chukuka Enwemeka 6

7 Dry Socket Most often caused by smoking after an extraction Blood clot falls out and bare bone exposed causes severe pain Reduces Pain Average 16J in socket, if pain not gone, continue with up to 48J or until pain stops 4J when changing dressing (no more than this as you are stimulating fibroblasts) Prevention best Endodontics After root canal completed or after pulpectomy After endodontic surgery As a diagnostic tool Reduction of post-op pain and inflammation Stimulation of osteoblasts for faster healing Reduced need for post-op analgesics Restorative Reduction of pain after deep preparation (filling) Reduce pain after crown and bridge preparations Reduces pain of exposure Dental Analgesia Phototherapy Inhibits unmyelinated C-fibers (the fibers which carry pulpal pain) Can be used in most primary teeth and in small restorations in adults Dr. Blake Clemes currently treating >95% of primary teeth in children with laser alone (no freezing) Nausea and Gagging Apply 8J to P6 acupuncture point bilaterally for reduced nausea and gagging Soft Tissue Lesions Herpes Simplex Apthous lesions Denture sores **Treat submandibular lymphatics first -Reduced Pain -Faster healing of lesions -Can prevent lesions in future 7

8 Literature Review The Effect of 670-nm Low Level Laser Therapy on Herpes Simplex 1 Jan Tuner et al Photomedicine and Laser Surgery 2012 The Effect of 670-nm Low Level Laser Therapy on Herpes Simplex 1 In a study of 232 patients treated with 670- nm laser irradiation, there was a demonstrated effect for both initial healing and for the length of recurrence periods Shown to be an effective treatment modality without any side effects Implants Less pain after surgery Faster and better integration of the implants into the bone (because it stimulates osteoblasts which form bone) Apply 8J into implant site in bone after implant is prepared Apply 2J overlapping along flap after suturing Treat 2-3x/week for 2 weeks Literature Review Study: Does the Use of Laser Photobiomodulation, Bone Morphogenetic Proteins and Guided Bone Regeneration Improve the Outcome of Autologous Bone Grafts? An in Vivo Study in a Rodent Model Results: Control group showed the most irregularities on the graft-bed interface, which had a crater-like aspect Using LLLT with Bone Morphogenetic Proteins resulted in a well-defined union between graph and surgical bed; resulted in a completely filled by corticol bone Results indicate that bone irradiated with infrared wavelengths shows increased osteoblastic proliferation, collagen deposition and bone neoformation, compared to non-irradiated bone Facial Pain Relief after Long Appointments Treatment of Facial Pain, Joint Pain, Osteoarthritis Apply after long appointment, molar root canal or anytime the patient experiences pain in the jaw 8

9 Nerve Regeneration Repair severed nerve after surgery Neuropathic Pain Orthodontics Sinusitis Lased Side Reduces pain and pressure in sinus Reduces the intensity of pain Increases speed of treatment Diabetes Mellitus - Pre-Gangrenous Right Foot Other Uses For Low Level Laser Therapy Initial Intermediate Final 6 weeks 58-y.o. female developed this Diabetic complication even with 3 months of conventional wound care The centre of lesion necrotic Arterial circulation of forefoot is impaired After completion of Laser therapy the ulcer has healed, arterial circulation restored and an amputation avoided Slide courtesy of Meditech International 9

10 Muscle Tear/Hematoma Rapid Wound Healing Initial After 3 Treatments After 5 Treatments 2 weeks Initial After 3 Treatments Over 5 Days Sports related injury: 2 Degree Strain of Left Hamstring muscle After 3 treatments in 5 days almost complete resolution. Slide courtesy of Meditech International 57-y.o. female sustained a fracture of Tibia and Fibula, underwent surgery Presented at Meditech on the fourth day following surgery in severe pain After 5 Laser treatments the pain subsided completely; edema and tenderness are diminished Minimal scarring is noted Slide courtesy of Meditech International Speaker: Dr. Gerry Ross, DDS ddsross@rogers.com For additional information, visit and Benefits of being a member: -Subscription to Photomedicine and Laser Surgery Journal includes access to all previous issues -Facebook Discussion Forums -Discounted registration to NAALT Conferences and events -Newsletter For more information and to register, members@naalt.org 10