The use of a diode laser scalpel in outpatient surgical dentistry. laser scalpel laser scalpel

David Kochiev, Ivan Shcherbakov
"Nature" №3, 2014

The unique ability of the laser to maximize energy concentration in space, time and spectral range make this device an indispensable tool in many areas of human activity, and in particular in medicine [,]. In the treatment of diseases, there is an intervention in the pathological process or a disease state, which is practiced in the most radical way by surgery. Thanks to progress in science and technology, mechanical surgical instruments are being replaced by fundamentally different ones, including laser ones.

Radiation and tissues

If laser radiation is used as an instrument, then its task is to cause changes in biological tissue (for example, perform a resection during surgery, start chemical reactions during photodynamic therapy). The parameters of laser radiation (wavelength, intensity, duration of exposure) can vary over a wide range, which, when interacting with biological tissues, makes it possible to initiate the development of various processes: photochemical changes, thermal and photodestruction, laser ablation, optical breakdown, generation of shock waves, etc.

On fig. 1 shows the wavelengths of lasers that have found some application in medical practice. Their spectral range extends from the ultraviolet (UV) to the mid-infrared (IR) region, and the range of energy densities covers 3 orders of magnitude (1 J/cm 2 - 10 3 J/cm 2), the range of power density - 18 orders of magnitude (10 −3 W /cm 2 - 10 15 W/cm 2), the time range is 16 orders, from continuous radiation (~10 s) to femtosecond pulses (10 −15 s). The processes of interaction of laser radiation with tissues are determined by the spatial distribution of the volumetric energy density and depend on the intensity and wavelength of the incident radiation, as well as on the optical properties of the tissue.

At the first stages of the development of laser medicine, a biological tissue was presented as water with “impurities”, since a person consists of 70–80% water and it was believed that the mechanism of the effect of laser radiation on biological tissue is determined by its absorption. With cw lasers, this concept was more or less workable. If it is necessary to organize an impact on the surface of a biological tissue, one should choose a wavelength of radiation that is strongly absorbed by water. If a volumetric effect is required, on the contrary, the radiation must be weakly absorbed by it. However, as it turned out later, other components of the biological tissue are also able to absorb (in particular, in the visible region of the spectrum - blood components, Fig. 2). The understanding came that biological tissue is not water with impurities, but a much more complex object.

At the same time, pulsed lasers began to be used. In this case, the impact on biological tissues is determined by a combination of the wavelength, energy density and duration of the radiation pulse. The latter factor, for example, helps to separate thermal and non-thermal effects.

Pulsed lasers with a wide range of pulse duration, from milliseconds to femtoseconds, have come into practice. Various nonlinear processes come into play here: optical breakdown on the target surface, multiphoton absorption, plasma formation and development, generation and propagation of shock waves. It became obvious that it is impossible to create a single algorithm for searching for the desired laser, and each specific case requires its own approach. On the one hand, this extremely complicated the task, on the other hand, it opened up absolutely fantastic opportunities to vary the methods of influencing biological tissue.

When radiation interacts with biological tissues, scattering is of great importance. On fig. Figure 3 shows two specific examples of the distribution of radiation intensity in the tissues of the prostate gland of a dog when laser radiation with different wavelengths is incident on its surface: 2.09 and 1.064 μm. In the first case, absorption prevails over scattering; in the second case, the situation is reversed (Table 1).

In the case of strong absorption, the penetration of radiation obeys the Bouguer-Lambert-Beer law, i.e., exponential decay takes place. In the visible and near IR wavelength ranges, the typical values ​​of the scattering coefficients of most biological tissues are in the range of 100–500 cm–1 and decrease monotonically with increasing radiation wavelength. With the exception of the UV and far IR regions, the scattering coefficients of a biological tissue are one to two orders of magnitude greater than the absorption coefficient. Under the conditions of dominance of scattering over absorption, a reliable picture of radiation propagation can be obtained using the diffuse approximation model, which, however, has quite clear limits of applicability, which are not always taken into account.

Table 1. Parameters of laser radiation and optical characteristics of the dog's prostate tissue

Thus, when using one or another laser for specific operations, one should take into account a number of nonlinear processes and the ratio of scattering and absorption. Knowledge of the absorbing and scattering properties of the selected tissue is necessary for calculating the distribution of radiation within the biological environment, determining the optimal dosage, and planning the results of exposure.

Mechanisms of interaction

Let us consider the main types of interaction between laser radiation and biological tissues, which are implemented using lasers in clinical practice.

The photochemical mechanism of interaction plays a major role in photodynamic therapy, when selected chromophores (photosensitizers) are introduced into the body. Monochromatic radiation initiates selective photochemical reactions with their participation, triggering biological transformations in tissues. After resonant excitation by laser radiation, the photosensitizer molecule undergoes several synchronous or successive decays, which cause intramolecular transfer reactions. As a result of a chain of reactions, a cytotoxic reagent is released, which irreversibly oxidizes the main cellular structures. Exposure occurs at low radiation power densities (~1 W/cm 2 ) and long periods of time (from seconds to continuous irradiation). In most cases, laser radiation in the visible wavelength range is used, which has a large penetration depth, which is important when it is required to influence deep tissue structures.

If photochemical processes occur due to the flow of a chain of specific chemical reactions, then thermal effects during the action of laser radiation on tissues, as a rule, are not specific. At the microscopic level, there is volumetric absorption of radiation due to transitions in molecular vibrational-rotational zones and subsequent nonradiative attenuation. The tissue temperature rises very efficiently, since the absorption of photons is facilitated by the huge number of available vibrational levels of most biomolecules and the numerous possible channels of relaxation during collisions. Typical photon energies are: 0.35 eV for Er:YAG lasers; 1.2 eV - for Nd:YAG lasers; 6.4 eV - for ArF lasers and significantly exceed the kinetic energy of the molecule, which at room temperature is only 0.025 eV.

Thermal effects in the tissue play a dominant role when using CW lasers and pulsed lasers with pulse durations of several hundred microseconds or more (free-running lasers). Removal of tissue begins after heating its surface layer to a temperature above 100°C and is accompanied by an increase in pressure in the target. Histology at this stage shows the presence of gaps and the formation of vacuoles (cavities) within the volume. Continued irradiation leads to an increase in temperature to values ​​of 350–450°C, burning and carbonization of the biomaterial occurs. A thin layer of carbonized tissue (≈20 µm) and a layer of vacuoles (≈30 µm) maintain a high pressure gradient along the tissue removal front, the rate of which is constant in time and depends on the type of tissue.

Under pulsed laser exposure, the development of phase processes is affected by the presence of an extracellular matrix (ECM). Boiling of water inside the volume of the tissue occurs when the difference in the chemical potentials of the vapor and the liquid phase, necessary for the growth of bubbles, exceeds not only the surface tension at the phase boundary, but also the elastic tension energy of the ECM, which is necessary to deform the matrix of the surrounding tissue. Bubble growth in tissue requires more internal pressure than in a pure liquid; an increase in pressure leads to an increase in the boiling point. The pressure builds up until it exceeds the tensile strength of the ECM tissue and results in removal and ejection of the tissue. Thermal tissue damage can vary from carbonization and melting on the surface to hyperthermia to a depth of several millimeters, depending on the power density and time of exposure to the incident radiation.

A spatially limited surgical effect (selective photothermolysis) is carried out with a pulse duration shorter than the characteristic thermal diffusion time of the heated volume - then the heat is retained in the affected area (it does not move even a distance equal to the optical penetration depth), and thermal damage to the surrounding tissues is small. Exposure to radiation from continuous lasers and lasers with long pulses (duration ≥100 μs) is accompanied by a larger zone of thermal damage to tissues adjacent to the area of ​​exposure.

Reducing the pulse duration changes the pattern and dynamics of thermal processes during the interaction of laser radiation with biological tissues. When the energy supply to the biomaterial is accelerated, its spatial distribution is accompanied by significant thermal and mechanical transient processes. Absorbing the energy of photons and heating up, the material expands, tending to go into a state of equilibrium in accordance with its thermodynamic properties and with the external conditions of the environment. The resulting inhomogeneity of the temperature distribution generates thermoelastic deformations and a compression wave propagating in the material.

However, the expansion or establishment of mechanical equilibrium in response to tissue heating takes a characteristic time equal in order of magnitude to the time required for a longitudinal acoustic wave to propagate through the system. When the duration of the laser pulse exceeds it, the material expands during the duration of the pulse, and the value of the induced pressure changes along with the intensity of the laser radiation. In the opposite case, the energy input to the system occurs faster than it has time to react mechanically to it, and the expansion rate is determined by the inertia of the heated tissue layer, regardless of the radiation intensity, and the pressure changes along with the value of the volume energy absorbed in the tissue. If we take a very short pulse (with a duration much shorter than the travel time of the acoustic wave through the heat release area), the tissue will be "inertially held", i.e., it will not receive time to expand, and heating will occur at a constant volume.

When the rate of energy release in the volume of the tissue upon absorption of laser radiation is much higher than the rate of energy loss for evaporation and normal boiling, the water in the tissue passes into a superheated metastable state. When approaching the spinodal, the fluctuation mechanism for the formation of nuclei (homogeneous nucleation) comes into play, which ensures the rapid decay of the metastable phase. The process of homogeneous nucleation manifests itself most clearly during pulsed heating of the liquid phase, which is expressed in the explosive boiling up of an overheated liquid (phase explosion).

Laser radiation can also directly destroy the biomaterial. The dissociation energy of chemical bonds of organic molecules is less than the photon energy of laser radiation in the UV range (4.0–6.4 eV) or comparable to it. When a tissue is irradiated, such photons, being absorbed by complex organic molecules, can cause a direct rupture of chemical bonds, carrying out the “photochemical decay” of the material. The interaction mechanism in the range of laser pulse durations of 10 ps - 10 ns can be classified as electromechanical, which implies plasma generation in an intense electric field (optical breakdown) and tissue removal due to shock wave propagation, cavitation, and jet formation.

Plasma formation on the tissue surface is typical for short pulse durations at radiation intensities on the order of 1010–1012 W/cm2, corresponding to a local electric field strength of ~106–107 V/cm. In materials that experience an increase in temperature due to a high value of the absorption coefficient, plasma can be created and maintained due to the thermal emission of free electrons. In media with low absorption, it is formed at high radiation intensities due to the release of electrons during multiphoton absorption of radiation and avalanche-like ionization of tissue molecules (optical breakdown). Optical breakdown makes it possible to “pump” energy not only into well-absorbing pigmented tissues, but also into transparent, weakly absorbing tissues.

Removal of tissues under exposure to pulsed laser radiation requires destruction of the ECM and cannot be considered simply as a process of dehydration upon heating. Destruction of ECM tissue is caused by pressures generated during phase explosion and limited boiling. As a result, an explosive ejection of material is observed without complete evaporation. The energy threshold of such a process is lower than the specific enthalpy of vaporization of water. Fabrics with high tensile strength require more high temperatures for the destruction of the ECM (the threshold volumetric energy density must be comparable with the enthalpy of vaporization).

Tools to choose from

One of the most common surgical lasers is the Nd:YAG laser, which is used in interventions with endoscopic access in pulmonology, gastroenterology, urology, in aesthetic cosmetology for hair removal, and for interstitial laser coagulation of tumors in oncology. In Q-switched mode, with pulse durations from 10 ns, it is used in ophthalmology, for example, in the treatment of glaucoma.

Most tissues at its wavelength (1064 nm) have a low absorption coefficient. The effective penetration depth of such radiation into tissues can be several millimeters and provides good hemostasis and coagulation. However, the amount of material removed is relatively small, and dissection and ablation of tissues may be accompanied by thermal damage to nearby areas, edema, and inflammation.

An important advantage of the Nd:YAG laser is the possibility of delivering radiation to the affected area by fiber optic light guides. The use of endoscopic and fiber instruments allows laser radiation to be delivered to the lower and upper gastrointestinal tract in an almost non-invasive way. Increasing the pulse duration of this Q-switched laser to 200–800 ns made it possible to use thin optical fibers with a core diameter of 200–400 µm for stone fragmentation. Unfortunately, absorption in optical fiber does not allow laser radiation to be delivered at wavelengths more efficient for tissue ablation, such as 2.79 µm (Er:YSGG ) and 2.94 µm (Er:YAG). To transport radiation with a wavelength of 2.94 μm at the Institute of General Physics (IOF) named after. A. M. Prokhorov, Russian Academy of Sciences, developed an original technology for the growth of crystalline fibers, with the help of which a unique crystalline fiber was made from leucosapphire, which was successfully tested. Transportation of radiation through commercially available optical fibers is possible for radiation with shorter wavelengths: 2.01 µm (Cr:Tm:YAG) and 2.12 µm (Cr:Tm:Ho:YAG) . The penetration depth of radiation of these wavelengths is small enough for effective ablation and minimization of accompanying thermal effects (it is ~170 μm for a thulium laser and ~350 μm for a holmium laser).

Dermatology has adopted both visible lasers (ruby, alexandrite, lasers with second harmonic generation by non-linear potassium titanyl phosphate crystals, KTP) and infrared wavelengths (Nd:YAG). Selective photothermolysis is the main effect used in laser treatment of skin tissues; indications for treatment - various vascular lesions of the skin, benign and malignant tumors, pigmentation, tattoo removal and cosmetic interventions.

Lasers on ErCr:YSGG (2780 nm) and Er:YAG (2940 nm) are used in dentistry to influence the hard tissues of the teeth in the treatment of caries and the preparation of the tooth cavity; during manipulations, there are no thermal effects, damage to the structure of the tooth and discomfort for the patient. KTP-, Nd:YAG-, ErCr:YSGG- and Er:YAG-lasers are involved in surgery on the soft tissues of the oral cavity.

Historically, the first area of ​​medicine that has mastered a new tool is ophthalmology. Work related to laser welding of the retina began in the late 1960s. The concept of "laser ophthalmology" has become commonplace; a modern clinic of this profile cannot be imagined without the use of lasers. Welding of the retina with light radiation has been discussed for many years, but only with the advent of laser sources did photocoagulation of the retina enter into wide daily clinical practice.

In the late 70s - early 80s of the last century, work began with lasers based on a pulsed Nd:YAG laser to destroy the lens capsule in the case of secondary cataract. Today, capsulotomy performed with a Q-switched neodymium laser is the standard surgical procedure in the treatment of this disease. A revolution in ophthalmology was made by the discovery that it was possible to change the curvature of the cornea with the help of short-wave UV radiation and thus correct visual acuity. Laser vision correction surgery is now widespread and performed in many clinics. Significant progress in refractive surgery and in a number of other minimally invasive microsurgical interventions (for corneal transplantation, creation of intrastromal channels, treatment of keratoconus, etc.) has been achieved with the introduction of lasers with short and ultrashort pulse durations.

Currently, solid-state Nd:YAG and Nd:YLF lasers (continuous, pulsed Q-switched pulses with a pulse duration of the order of several nanoseconds and femtosecond) are the most popular in ophthalmological practice, to a lesser extent - Nd:YAG lasers with a wavelength of 1440 nm in the free-running regime, Ho and Er lasers.

Since different parts of the eye have different composition and different absorption coefficient for the same wavelength, the choice of the latter determines both the segment of the eye on which the interaction will occur and the local effect in the focus area. Based on the spectral characteristics of the transmission of the eye, it is advisable to use lasers with a wavelength in the range of 180–315 nm for surgical treatment of the outer layers of the cornea and the anterior segment. Deeper penetration, up to the lens, is possible in the spectral range of 315–400 nm, and radiation with a wavelength of more than 400 nm and up to 1400 nm, when significant absorption of water begins, is suitable for all far regions.

Physics - medicine

Taking into account the properties of biological tissues and the type of interaction realized during the incidence of radiation, the Institute of General Physics develops laser systems for use in various fields of surgery, collaborating with many organizations. The latter include academic institutions (Institute for Problems of Laser and Information Technologies - IPLIT, Institute of Spectroscopy, Institute of Analytical Instrumentation), Moscow State University. M. V. Lomonosov, leading medical centers of the country (MNTK "Eye Microsurgery" named after S. N. Fedorov, Moscow Research Oncological Institute named after P. A. Herzen of Roszdrav, Russian Medical Academy of Postgraduate Education, Scientific Center for Cardiovascular surgery named after A. N. Bakulev RAMS, Central Clinical Hospital No. 1 of JSC Russian Railways), as well as a number of commercial companies (Optosystems, Visionics, New Energy Technologies, Laser Technologies in Medicine, Cluster, Scientific and Technical Center " Fiber optic systems).

Thus, our institute has created a laser surgical complex "Lazurit", which can act as both a scalpel-coagulator and a lithotriptor, i.e. a device for destroying stones in human organs. Moreover, the lithotriptor works on a new original principle - radiation with two wavelengths is used. This is a laser based on a Nd:YAlO 3 crystal (with a fundamental wavelength of 1079.6 nm and its second harmonic in the green region of the spectrum). The unit is equipped with a video information processing unit and allows you to monitor the operation in real time.

Two-wave laser action of microsecond duration provides a photoacoustic mechanism of stone fragmentation, which is based on the optical-acoustic effect discovered by A. M. Prokhorov and co-workers - the generation of shock waves during the interaction of laser radiation with a liquid. The impact turns out to be nonlinear [ , ] (Fig. 4) and includes several stages: optical breakdown on the stone surface, formation of a plasma spark, development of a cavitation bubble, and propagation of a shock wave during its collapse.

As a result, after ~700 µs from the moment the laser radiation falls on the surface of the stone, the latter is destroyed due to the impact of the shock wave generated during the collapse of the cavitation bubble. The advantages of this method of lithotripsy are obvious: firstly, it ensures the safety of the impact on the soft tissues surrounding the stone, since shock wave they are not absorbed and, therefore, do not harm them, inherent in other laser methods of lithotripsy; secondly, high efficiency is achieved in the fragmentation of stones of any localization and chemical composition (Table 2); thirdly, a high fragmentation rate is guaranteed (see Table 2: the duration of stone destruction varies in the range of 10–70 s depending on their chemical composition); fourthly, the fiber tool is not damaged during radiation delivery (due to the optimally selected pulse duration); finally, the number of complications is radically reduced and the postoperative period of treatment is shortened.

Table 2. Chemical composition stones and parameters of laser radiation during fragmentation in experiments in vitro

The complex "Lazurit" (Fig. 5) also includes a scalpel-coagulator, which allows, in particular, to successfully perform unique operations on blood-filled organs, such as the kidney, to remove tumors with minimal blood loss, without clamping the renal vessels and without creating artificial ischemia organ, accompanying the currently accepted methods of surgical intervention. Resection is performed with laparoscopic access. With an effective penetration depth of pulsed one-micron radiation of ~1 mm, tumor resection, coagulation, and hemostasis are performed simultaneously, and wound ablasticity is achieved. A new medical technology for laparoscopic nephrectomy in T 1 N 0 M 0 cancer has been developed.

The results of research work in the field of ophthalmology were the development of ophthalmic laser systems "Microscan" and its modification "Microscan Visum" for refractive surgery based on the ArF-excimer laser (193 nm). With the help of these settings, myopia, hyperopia and astigmatism are corrected. The so-called "flying spot" method has been implemented: the cornea of ​​the eye is illuminated by a spot of radiation with a diameter of about 0.7 mm, which scans its surface according to an algorithm set by a computer and changes its shape. Vision correction by one diopter at a pulse repetition rate of 300 Hz is provided in 5 s. The impact remains superficial, since radiation with this wavelength is strongly absorbed by the cornea of ​​the eye. The eye tracking system ensures high quality of the operation, regardless of the mobility of the patient's eye. The Microscan device is certified in Russia, the CIS countries, Europe and China, and 45 Russian clinics are equipped with it. Ophthalmic excimer systems for refractive surgery, developed at our institute, currently occupy 55% of the domestic market.

With the support of the Federal Agency for Science and Innovation, with the participation of the GPI RAS, IPLIT RAS and Moscow State University, an ophthalmological complex was created, including Microscan Visum, diagnostic equipment consisting of an aberrometer and a scanning ophthalmoscope, as well as a unique Femto Visum femtosecond laser ophthalmological system . The birth of this complex became an example of fruitful cooperation between academic organizations and the Moscow state university within the framework of a single program: a surgical instrument was developed at the IOF, and diagnostic equipment was developed at Moscow State University and IPLIT, which makes it possible to carry out a number of unique ophthalmological operations. The principle of operation of a femtosecond ophthalmological unit should be considered in more detail. It was based on a neodymium laser with a wavelength of 1064 nm. If the cornea absorbs strongly in the case of an excimer laser, then at a wavelength of ~1 μm the linear absorption is weak. However, due to the short pulse duration (400 fs), when the radiation is focused, it is possible to achieve a high power density, and, consequently, multiphoton processes become effective. With the organization of appropriate focusing, it turns out that it is possible to influence the cornea in such a way that its surface is not affected in any way, and multiphoton absorption is carried out in volume. The mechanism of action is photodestruction of corneal tissues during multiphoton absorption (Fig. 6), when there is no thermal damage to nearby tissue layers and intervention with precision is possible. If for radiation of an excimer laser the photon energy (6.4 eV) is comparable to the dissociation energy, then in the case of one-micron radiation (1.2 eV) it is at least twice, or even seven times less, which ensures the described effect and opens new opportunities in laser ophthalmology.

Photodynamic diagnostics and cancer therapy based on the use of a laser, whose monochromatic radiation excites the fluorescence of a photosensitizing dye and initiates selective photochemical reactions that cause biological transformations in tissues, are being intensively developed today. Doses of dye administration are 0.2–2 mg/kg. In this case, the photosensitizer mainly accumulates in the tumor, and its fluorescence makes it possible to establish the localization of the tumor. Due to the effect of energy transfer and an increase in laser power, singlet oxygen is formed, which is a strong oxidizing agent, which leads to the destruction of the tumor. Thus, according to the described method, not only diagnosis, but also treatment is carried out. oncological diseases. It should be noted that the introduction of a photosensitizer into the human body is not a completely harmless procedure, and therefore in some cases it is better to use the so-called laser-induced autofluorescence. It turned out that in some cases, especially with the use of short-wavelength laser radiation, healthy cells do not fluoresce, while cancer cells show the effect of fluorescence. This technique is preferable, but so far it serves mainly diagnostic purposes (although steps have recently been taken to realize a therapeutic effect). Our institute has developed a series of devices for both fluorescent diagnostics and photodynamic therapy. This equipment is certified and mass-produced; 15 Moscow clinics are equipped with it.

For endoscopic and laparoscopic operations, a necessary component of the laser installation is the means of delivering radiation and forming its field in the area of ​​interaction. We have designed such devices based on multimode optical fibers that allow us to work in the spectral region from 0.2 to 16 microns.

With the support of the Federal Agency for Science and Innovation, the IOF is developing a method for searching for the size distribution of nanoparticles in liquids (and in particular, in human blood) using quasi-elastic light scattering spectroscopy. It was found that the presence of nanoparticles in a liquid leads to a broadening of the central Rayleigh scattering peak, and measuring the magnitude of this broadening makes it possible to determine the size of the nanoparticles. The study of the size spectra of nanoparticles in the blood serum of patients with cardiovascular disorders showed the presence of large protein-lipid clusters (Fig. 7). It was also found that large particles are also characteristic of the blood of cancer patients. Moreover, with a positive result of treatment, the peak responsible for large particles disappeared, but reappeared in case of recurrence. Thus, the proposed technique is very useful for diagnosing both oncological and cardiovascular diseases.

Earlier, the institute developed a new method for detecting extremely low concentrations of organic compounds. The main components of the instrument were a laser, a time-of-flight mass spectrometer, and a nanostructured plate on which the gas under study was adsorbed. Today, this unit is being modified for blood analysis, which will also open up new opportunities for the early diagnosis of many diseases.

The solution of a number of medical problems is possible only by combining efforts in several areas: this and fundamental research in laser physics, and a detailed study of the interaction of radiation with matter, and analysis of energy transfer processes, and biomedical research, and the development of medical treatment technologies.

4 YSGG- Yttrium Scandium Gallium Garnet(yttrium-scandium-gallium garnet).

YLF- Yttrium Lithium Fluoride(yttrium-lithium fluoride).

Circumcision (circumcision) is a surgical operation during which the male penis remove the foreskin. This procedure is optional, but sometimes it is performed for various reasons: medical, religious, etc. Today, circumcision is performed using a traditional scalpel or a modern laser. Which one is better and safer?

The laser method is used not only in circumcision, but also in the removal of various cosmetic defects (moles, papillomas, warts, etc.), erosion of the neck of a T-shirt. The laser beam “burns” the layers of the skin, as a result of which the neoplasms are eliminated.

During the operation, the surgeon pulls the foreskin and pulls it tightly. Then he acts on the skin with a laser beam, and the foreskin is excised. Self-absorbable sutures and a disinfectant bandage are applied to the impact site.

The operation is performed under local anesthesia and lasts 20-30 minutes. The advantages of laser cutting are:

1. Minimal injury. The laser beam cuts soft tissues as evenly as possible, without shredding, unlike a scalpel. Due to this, pain and swelling in the first days after the operation are not so pronounced.
2. No bleeding. The blood vessels are coagulated by the laser, so there is no bleeding.
3. Sterility. Laser radiation heats the layers of the skin, and as a result, everything pathogenic microorganisms die at high temperatures.
4. Quick Recovery. Rehabilitation after laser circumcision lasts several times shorter than after scalpel. Patients return to their usual way of life (with some restrictions) after 3-5 days.
5. High aesthetic result. After laser cutting, there are no stitches, scars and scars, as the edges of the wound are sealed and self-absorbable sutures are applied.
6. Safety and minimal risk of complications. After exposure to a laser, inflammatory processes and other pathologies very rarely occur, so this method is the safest.

The disadvantage of this procedure is only its relatively high cost - scalpel circumcision is much cheaper.

The scalpel is the main surgical instrument during operations. It is a small sharp knife, which is used to cut and excise soft tissues.

Before surgery, the patient must be injected analgesic injections. Then the penis is tied with a special thread near the head, so as not to accidentally touch the tissues that do not need to be cut off with a scalpel.

After bandaging, the surgeon pulls back the foreskin and excised it with a scalpel. After that, self-absorbable sutures are applied to the site of exposure. Previously, soft tissues were blotted with swabs during the operation to stop bleeding. To date, during the operation, coagulators (electrodes) are also used, which cauterize blood vessels and stop bleeding.

Comparison

A laser and a scalpel are used to remove the foreskin of the penis - this significantly reduces the risk of developing infectious diseases genitourinary system, the hygienic condition of the penis improves (since dirt and various secretions cease to accumulate under the head, which are a favorable environment for the reproduction of bacteria), sexual intercourse lengthens.

Both methods are equally popular today. The scalpel method is chosen by many patients, as it is more familiar, and many know its principle of operation. However, this method, in comparison with the laser, has several disadvantages:

• Causes bleeding (but blood droplets are cauterized by electrodes).
• There is a risk of infection.
• The operation takes 2 times longer.
• The doctor may accidentally cut off an extra piece of skin.
• Longer rehabilitation period (up to 1 month).
• Unpleasant sensations after surgery are more pronounced than after laser exposure.

Both laser and scalpel circumcision can be performed any age- the operation is done even for babies a few days after birth.

Contraindications for both procedures are the same:

• Oncological diseases.
• Blood diseases, blood clotting disorders.
• Immune disorders.
• Viral and colds.
• Infectious and inflammatory pathologies.
• Sexual infections.
• Venereal diseases.
• HIV and AIDS.
• Unhealed injuries in the circumcision area.

After circumcision (in any way), visit a sauna, bath, swimming pool for some time, take a bath (wash in the shower), physical exercise. Usually the restrictions are removed 2 weeks after the operation.

What's better

Today, the laser is safer and modern way removal of the foreskin - it does not cause bleeding, gently excised soft tissues, has a short rehabilitation period. Therefore, it is preferable to choose this method.

The scalpel method is suitable for those who are not ready to pay a large amount for the procedure. Sometimes surgery for medical reasons is performed free of charge in public hospitals.

Before the operation, you will need to pass some tests (for sexual infections, HIV, blood and urine tests) and undergo a series of examinations to rule out contraindications. It is also necessary to consult a doctor and decide together with him which method of circumcision to use - laser or scalpel. Sometimes it happens that the foreskin can only be removed with a scalpel. Also, together with the doctor, the patient decides how much foreskin can be removed.

Circumcision should be experienced surgeon. The inexperience of the doctor can lead to serious complications. It is best to pay money and have the operation done in a specialized clinic. It should be borne in mind that the clinic must have a license.

Organization-developer: Federal State Institution "Central Research Institute of Dentistry and Maxillofacial Surgery of the Federal Agency for High-Tech Medical Care".

Medical technology involves the use of a laser scalpel with a wavelength of 0.97 μm in the surgical treatment of patients with diseases of the periodontium, oral mucosa and lips, benign neoplasms of the oral cavity and lips, and anatomical and topographic features of the structure of the soft tissues of the oral cavity, which improves efficiency. treatment, reduce the likelihood of complications and relapses, pain patient and time of his disability.

The medical technology is intended for dental and maxillofacial surgeons who have been trained to work with laser medical devices.

Can be used in dental clinics and departments of maxillofacial surgery.

Reviewers: head Department of propaedeutic dentistry GOU VPO "MGMSU Roszdrav" doc. honey. sciences, prof. E.A. Bazikyan; head Department of Dentistry GOU DPO "RMAPO Roszdrav" Dr. honey. sciences, prof. I.A. Shugailov.

Introduction

The creation of new medical equipment based on the achievements of modern science and technology makes it possible to develop new medical technologies that have undoubted advantages over existing methods. The use of new technologies makes it possible to increase the effectiveness of treatment, reduce the likelihood of complications and relapses, the patient's pain sensations and the time of his disability. Among these technologies, a significant place is occupied by laser technologies.

With the advent of a new laser surgical technique in dental practice, it became possible to choose the wavelength of the working radiation and the temporary mode of operation (continuous, pulsed or repetitively pulsed). High reliability, ease of control, low weight and dimensions make it possible to use modern laser scalpels based on powerful semiconductor (diode) and fiber lasers in medical institutions that do not have engineering services, while reducing their operating costs. Low sensitivity to external influences, combined with low power consumption, allows the use of such devices in non-clinical conditions.

The results of the research showed the advantages of laser treatment: coagulation of vessels in the incision zone, less trauma, asepticity and ablasticity of the wound surface, easier postoperative period, no side effects on the body, the formation of a thin, delicate, little noticeable scar.

The impact of the laser beam is carried out with high accuracy on any size areas of biological tissue on groups and individual cells. The most sparing effect on soft tissues and oral mucosa makes it possible to reduce swelling and the zone of thermal damage, and the strength of the edges of wounds after laser exposure allows them to be sutured.

Indications for the use of medical technology

1. Periodontal diseases (epulis, hypertrophic gingivitis, pericoronitis).
2. Diseases of the mucous membrane of the mouth and lips (long-term non-healing erosion of the mucous membrane of the tongue and cheeks, limited hyper- and parakeratosis, erosive and ulcerative form of lichen planus, leukoplakia).
3. Benign neoplasms of the oral cavity and lips (fibroma, retention cyst of the minor salivary glands, ranula, hemangioma, radicular cyst, candyloma, papilloma).
4. Anatomical and topographic features of the structure of the soft tissues of the oral cavity (small vestibule of the oral cavity, short frenulum of the tongue, short frenulum of the upper and lower lips).

Contraindications to the use of medical technology

1. Diseases of the cardiovascular system in the stage of decompensation.
2. Diseases nervous system with a sharp increase in excitability.
3. Hyperthyroidism.
4. Pronounced and severe degree of emphysema.
5. Functional failure of the kidneys.
6. Severe degree diabetes in an uncompensated state or with unstable compensation.

Logistics of medical technology

Laser scalpel programmable three-mode portable LSP-"IRE-Pole" with a wavelength of 0.97 microns (NTO "IRE-Polyus", Russia). Registration certificate of the Ministry of Health of the Russian Federation No. 29/01040503/2512-04 dated 09.03.2004

Description of medical technology

Characteristics of laser radiation and technical characteristics of the laser device

Optimum properties in the implementation of surgical interventions on the soft tissues of the oral cavity is laser radiation with a wavelength of 0.97 μm. On fig. Figure 1 shows the dependence of the wavelength of laser radiation on the value of its absorption in water and whole blood.

This is the main parameter that determines the depth at which laser radiation is absorbed, and hence the nature of its effect on biological tissues.

Rice. one.

These dependences can be qualitatively used in assessing the depth of penetration of radiation into real biological tissues. From fig. 1 shows that the radiation wavelength of 0.97 μm falls on the local absorption maximum in water and blood. In this case, the absorption depth is 1-2 mm. In addition to absorption on the penetration depth of radiation, a significant influence is exerted by the scattering coefficient, the value of which in whole blood exceeds the absorption coefficient and in the specified range is about 0.65 mm -1 . Due to scattering, radiation in a biological tissue propagates not only along the original direction, but also to the sides. In addition, it should be taken into account that the biophysical state of the biological tissue and the nature of absorption change during laser exposure. So, when heated to a temperature above about 150 o C, hydrogen burns out and charring of the biological tissue occurs, at which the absorption increases sharply.

The impact of laser radiation on biological tissues can be carried out remotely or by contact. Most often, when working on soft tissues, a contact effect with a fiber tool is used. During the contact action, the distal end of the working quartz fiber is cleared of the protective plastic shell at a distance of approximately 5 mm and brought into contact with the biological tissue. The presence of physical contact allows you to accurately localize the impact. Contact with biological tissue eliminates the reflection of radiation into the surrounding space. With sufficient radiation power at the point of contact, the fiber is contaminated by the products of tissue combustion and increased heat generation and the resulting heating of the end of the fiber. In this case, the biotissue is subjected to a combined effect of laser radiation and the hot end of the light guide.

Remote exposure is mainly used for surface treatment of wound surfaces for the purpose of their sanitation and coagulation. In this case, it should be taken into account that the working radiation comes out of the flat end of the light guide in the form of a cone with an angle at the top of about 25 o and coincides with the visible radiation of the targeting laser.

The unique properties of the laser beam provide undeniable advantages over traditional methods of treating oral diseases:

1. High precision of laser exposure due to the use of contact technique.
2. Minimal blood loss. Good coagulating abilities of laser radiation allow operating on patients with blood clotting disorders.
3. The small depth of the affected area and the evaporation of tissues during laser exposure contributes to the formation of a thin coagulation film on the tissue surface, which avoids the risk of bleeding associated with rejection of the scab in the postoperative period.
4. A small zone of thermal damage to adjacent tissues reduces postoperative edema and inflammatory response at the border of the necrosis zone, due to which rapid epithelialization occurs, which significantly reduces the time of wound regeneration.
5. The high local temperature in the impact zone creates conditions for the sanitation of the operating area, reduces the likelihood of infection of the operating wound. This contributes to the acceleration of wound healing and reduces the likelihood of postoperative complications.
6. Preservation of the structure of biological tissue at the edges of the wound allows, if necessary, suturing the wound.
7. Due to the low penetrating power of radiation and slight tissue damage, rough scars are not formed, and the mucous membrane is well restored.
8. Laser treatment is slightly painful, which reduces the amount of anesthesia and in many cases eliminates it altogether.

Table 1. Technical characteristics of the device LSP-"IRE-Pole".

Rice. 2. Appearance device LSP-"IRE-Pole".

Methodology

All surgical interventions were performed under local anesthesia using the LSP-"IRE-Polus" apparatus (hereinafter referred to as LSP) with a wavelength of 0.97 μm in repetitively pulsed and continuous modes, at a power of 2-5 W.

Method for the treatment of patients with benign neoplasms of the oral cavity

When removing benign and tumor-like neoplasms of the oral cavity and lips (including fibromas, retention cysts of the minor salivary glands, ranulas, hemangiomas, radicular cysts, condylomas, papillomas), two methods of laser exposure are used:

1. Small neoplasms (up to 0.2-0.3 cm) are removed using the ablation method (power - 2-4 W, in continuous and repetitively pulsed modes with pulse duration - 500-1000 ms, pause duration - 100-500 ms) .
2. Neoplasms of large sizes (more than 0.2-0.3 cm) are removed using the laser excision method (power - 3-5 W, in continuous and repetitively pulsed modes with a pulse duration of -1000-2000 ms and a pause duration of 100-1000 ms ).

If, according to indications, it becomes necessary to conduct a biopsy of the tumor, then it is performed using the laser excision method (laser excision method).

When removing a fibroma, a laser excision of the formation is performed using the laser excision method. Under infiltration anesthesia (Ultracain), the neoplasm is excised in a pulse-periodic mode with a power of 5 watts. The postoperative wound is sutured with a Vicryl thread (Fig. 3).

Rice. 3.
a- before treatment;
b- on the 5th day after surgery;
in- on the 10th day after surgery;
G- after 1 month.

A laser scalpel can be used to remove almost all types of benign neoplasms of the oral cavity and lips, including tumor-like formations (radicular cysts). The laser method for treating this pathology consists in thorough ablation of the cyst membrane in continuous or pulse-periodic modes (pulse duration - 500-1000 ms, pause duration - 100-500 ms) and at a power of 2-4 W. After laser ablation, the cyst shell is easily removed, while using the instrumental method it is almost impossible to do this without resection of the apex of the tooth root.

Treatment of simple hemangiomas and retention cysts of small salivary glands with a laser consists in the use of 2 methods of laser exposure:

1. Insertion of a light guide into the cavity of a hemangioma or cyst and its ablation. At the same time, the size of neoplasms: for hemangiomas - 0.5-0.7 cm in diameter, for retention cysts of small salivary glands - up to 1 cm in diameter.
2. Autopsy in progress top wall neoplasms with a laser beam, vaporization of the contents and careful ablation of the bed.

In the treatment of this pathology, a continuous or pulse-periodic mode is used with a pulse duration of 500-1000 ms, a pause of 100-500 ms and a power of 2.5-4.5 W.

According to the above method, laser excision of the tumor is performed with wound closure by bringing the edges closer together. Under infiltration anesthesia (Ultracain), two crescentic incisions of the mucous membrane are performed with a laser scalpel in a pulse-periodic mode with a power of 4 W. The cyst is removed by semi-blunt exfoliation from the surrounding tissues. For a more complete removal of the cyst membrane, a thorough ablation of the bottom of the cystic cavity is performed with a laser beam (in the same mode at a power of 2.5 W) (Fig. 4).

Rice. four.
a- before treatment;
b- during surgery
in
G- after 1 month.

Surgical treatment of patients with periodontal diseases

In the treatment of periodontal tissue diseases, such as epulis, hypertrophic gingivitis, pericoronitis, a power of 3-5 W is used, in continuous and pulse-periodic modes (with a pulse duration of 500-2000 ms and a pause duration of 100-1000 ms).

Among periodontal diseases in outpatient surgical dentistry, the most common type of pathology is epulis. In this case, the fiber laser scalpel has the advantage that, on the light guide, the laser radiation can be simply guided to any treatment areas. Under laser exposure, the growth point of the epulis in the bone tissue of the interdental septa of the alveoli of the teeth is destroyed. With this method of treatment, relapses are almost completely absent.

When the epulis is removed, infiltration anesthesia (Ultracain) is performed, then the formation is excised in a pulse-periodic mode with a power of 6 W (Fig. 5).

Rice. 5.
a- before treatment;
b- immediately after the intervention;
in- after 2 days. after operation;
G- 6 months after surgery.

In the treatment of hypertrophic gingivitis (Fig. 6), pathologically altered tissue is excised using laser radiation, also under infiltration anesthesia (Ultracain) in a pulse-periodic mode with a power of 4 W. Excision of the formation is carried out by laser excision of the soft tissue of the gums to the bone, departing from the visible border of the pathologically altered tissue by 2 mm. The wound surface is then ablated.

At the site of laser exposure, a coagulation film is formed, which reliably protects the wound surface from saliva and oral microflora. For better fixation of the flap, guide sutures are applied.

Simultaneously (simultaneously) according to indications, frenuloplasty is performed upper lip(Fig. 6c).

Rice. 6. Treatment of moderate hypertrophic gingivitis
in the area of ​​the frontal group of teeth on the upper jaw,
a- before the operation;
b- immediately after the intervention;
in- after frenulum correction;
G- 1 day after the operation;
d
e- after 6 months. after operation.

Pericoronitis is a common complication of difficult eruption of the wisdom tooth (according to the classification of ICD 10 of the 5th revision, pericoronitis refers to periodontal diseases, so pericoronitis is included in this section of the pathology). Existing conservative ways treatments for pericoronitis are usually unsuccessful, and excision of the hood with the traditional method does not always lead to the desired result. The hood of the wisdom tooth is excised with a laser beam by means of an oval (marginal) gum incision 2-3 mm above the neck of the tooth. Previously, a trowel or spatula is inserted under the hood, slightly pulling the hood away from the chewing surface of the tooth. The excision of the hood is carried out with a laser scalpel in continuous or pulse-periodic modes (with a pulse duration of 1000-2000 ms and a pause of 100-500 ms) and at a power of 3-4 W. Ablation is carried out with a beam at a device power of 2-3 watts.

The advantage of this method is the possibility of excision of the hood with a laser beam, followed by the formation of a coagulation film along the incision line, which provides reliable hemostasis, minimal edema, protection against the macerating effect of saliva and microflora, rapid epithelization, as well as the exclusion of the formation of microhematomas, a tight fit of the gingival margin to the neck of the tooth, excluding the formation of a periodontal pocket, suppuration and the occurrence of other complications.

According to the method described above, the wisdom tooth hood is excised with laser radiation under conduction and infiltration anesthesia (Ultracaine) in a pulse-periodic mode with a power of 4.5 W. Then the wound surface is ablated in the same mode at a power of 2.5 W in order to create a protective coagulation film that prevents bleeding, forms a reliable protective barrier and stimulates effective epithelization of the wound surface (Fig. 7).

Rice. 7.
a- before treatment;
b- after surgery;
in- on the 7th day after surgery;
G

Treatment of patients with anatomical and topographic features of the structure of soft tissues of the oral cavity

With the help of a laser scalpel, surgical interventions are carried out with high efficiency in case of anatomical and topographic features of the structure of the soft tissues of the oral cavity: a small vestibule of the oral cavity, a short frenulum of the tongue, a short frenulum of the upper and lower lips. For treatment, the following parameters are used: continuous and pulse-periodic modes (with a pulse duration of 500-2000 ms and a pause of 100-1000 ms); power - 2.5-5 watts.

After exposure to a laser beam, the wound surface is covered with a coagulation film and, when small sizes suture defect is not required.

Under infiltration anesthesia (Ultracain) in a pulse-periodic mode with a power of 5 W, the frenulum of the upper lip is excised at the site of its attachment. The resulting wound surface is then ablated in the same mode at a power of 2.5 W in order to create a coagulation film (Fig. 8).

Healing proceeds under iodoform turunda or without it and without suturing.

Rice. eight.
a- before the operation;
b- after surgery;
in- 7 days after the operation;
G- after 1 month. after operation.

Vestibuloplasty according to Edlan-Meikher (Fig. 9) is performed under conduction and infiltration anesthesia (Ultracain) using the method of hydropreparation in a pulse-periodic mode with a power of 4 W. The exfoliated mucous flap is fixed to the periosteum using "laser welding" of soft tissues.

Rice. 9.
a- before the operation;
b- after surgery;
in- on the 2nd day after the operation;
G- 12 days after the operation;
d, e- 1 and 3 months after surgery.

Treatment of patients with diseases of the oral mucosa

In the treatment of diseases of the mucous membrane of the mouth and lips, namely, long-term non-healing erosion of the mucous membrane of the tongue and cheeks, limited hyper- and parakeratosis, erosive-ulcerative form of lichen planus and leukoplakia, the following optimal modes are used: power - 3.5-5.5 W, pulse duration - 500-2000 ms, pause duration - 100-1000 ms. The essence of the method lies in the layer-by-layer ablation (evaporation) of pathologically altered tissues or in the removal using the laser excision method. In this case, a coagulation film is formed, which reliably protects the wound surface from the macerating effect of saliva and its microflora and, most importantly, ensures effective tissue epithelialization.

Under infiltration anesthesia (Ultracain), according to the above described technique in a pulse-periodic mode with a power of 3.5 W, laser ablation of the altered part of the mucous membrane is performed with the formation of a protective coagulation film (Fig. 10).

Rice. ten.
a- before the operation;
b- immediately after the operation;
in- on the 7th day after the operation;
G- 21 days after surgery.

Possible complications when using medical technology and ways to eliminate them

When a pain reaction and swelling appear, analgesic and anti-inflammatory therapy is prescribed.

In case of recurrence of the disease, repeated treatment is carried out using laser technology.

Efficiency in the use of medical technology

This technology is based on the experience of using laser radiation with a wavelength of 0.97 μm in the department of outpatient surgical dentistry of the Central Research Institute of Dentistry in the period 2003-2006. During this period, 200 patients were examined and treated. There were 47 men (23.5%), women - 153 (76.5%). The patients' age ranged from 8 to 82 years.

Statistics on the use of the proposed methods of treatment, taking into account the nosological forms of diseases are given in table. 2.

Table 2. Distribution of patients by sex, taking into account the nosological form of the disease.

For the treatment of patients with benign neoplasms of the mouth and lips laser technology was used in 113 people (fibromas - in 49 people, retention cysts of minor salivary glands - in 11, ranula - in 11, hemangiomas - in 15, radicular cyst - in 9, condylomas - in 2, papillomas - in 16 people) . There were 89 women, 24 men.

The results of treatment of 113 patients with benign lesions of the oral cavity and lips were analyzed. In 16 (14.1%) patients, a slight pain reaction was observed after laser exposure, in 36 (31.8%) patients there was a slight swelling of the surrounding soft tissues.

No complications were observed in the late postoperative period in any case.

After excision of the neoplasms, all the obtained material was sent for histological examination. Histology was confirmed.

After 1 month at the control examination, 4 (3.5%) patients had a tumor recurrence. In 2 cases, a simple hemangioma was found, and in one case - fibroma and ranula.

In 3 patients (2.6%), histological examination revealed a malignant neoplasm. Patients were referred to specialized institutions for further treatment.

Laser technology was used in 44 patients with periodontal disease(epulis - in 30 people, hypertrophic gingivitis - in 7, pericoronitis - in 7 people). There were 33 women, 11 men.

Analysis of the results of treatment of patients with periodontal disease showed that all patients had no bleeding during surgery. A slight collateral soft tissue edema was observed in 8 (18.2%) patients. In 11 (25%) patients after laser exposure, there was a slight pain reaction in the postoperative area. Difficulty opening the mouth, pain and swelling of soft tissues occurred in 3 (6.8%) patients and persisted for several days after surgery.

Relapse was observed in 3 (6.8%) patients of this group. Epulis recurrence was found in 2 patients and pericoronitis in one case. Also, in one (2.3%) patient after histological examination a malignant neoplasm was detected. The patient was referred to a specialized institution for further treatment.

Laser technology was applied in 31 patients with anatomical and topographic features of the structure of soft tissues of the oral cavity(a short frenulum of the upper lip - in 20 people, a small vestibule of the oral cavity - in 7, a short frenulum of the tongue - in 4 people). There were 23 women, 8 men.

After laser exposure, the pain reaction in the postoperative area was mild or absent, and a slight swelling of the soft tissues adjacent to the operating area was observed only in 8 (25%) patients. Hyperemia of the mucous membrane around the wound surface was also mild or absent. The integrity of the oral mucosa fully recovered on the 10-14th day after the operation.

The results of treatment after the laser exposure were good in all 31 patients. The immediate and remote control showed the presence of a thin, barely noticeable scar at the site of laser exposure and the absence of signs of an inflammatory process in the tissues.

For the treatment of patients with diseases of the oral mucosa, laser radiation with a wavelength of 0.97 μm was carried out in 12 patients. There were 8 women and 4 men.

Analysis of the results of treatment of 12 patients with diseases of the oral mucosa (long-term non-healing erosion of the mucous membrane of the tongue and cheeks - 2 (1.3%) patients, limited hyper- and parakeratosis - 4 (2.7%), erosive and ulcerative form of lichen planus - 2 (1.3%), leukoplakia - 4 (2.7%) patients) using a diode laser scalpel showed that 5 (41%) patients had mild pain after laser exposure, 1 (8.3%) patient in the postoperative area, the pain was severe. Minor soft tissue edema was observed in 7 (58%) patients. The mucous membrane around the surgical field was hyperemic as a border in 7 (58%) patients. The integrity of the oral mucosa fully recovered by 10-14 days.

Relapse of leukoplakia was observed in one case (8.3% of patients). In one patient, histological examination revealed a malignant neoplasm. The patient was referred to a specialized institution for further observation and treatment.

Thus, the analysis of the clinical application of the apparatus LS-0.97-"IRE-Pole" with a wavelength of 0.97 μm for the treatment of patients with various nosological forms of diseases of the oral mucosa and periodontal disease showed that the proposed medical technology is highly effective. Of the 200 patients who underwent treatment, positive results were achieved in 197 (98.5%) people.

The use of laser technologies makes it possible to improve the technique of surgical treatment of patients with diseases of the soft tissues of the oral cavity, oral mucosa and periodontal disease. Laser radiation, when exposed to biological tissues, provides a combination of good cutting and coagulating properties. The control of the operating modes of laser devices allows performing operations on the soft tissues of the oral cavity atraumatically, with minimal damage to the surrounding and underlying tissues.

Laser devices of the new generation have a number of advantages, which, along with a reduction in the consumption of medicines and an increase in labor productivity, gives a significant economic effect.

Operations performed using laser radiation are easily tolerated by patients and can be applied both in inpatient and outpatient settings. It is necessary to widely introduce new generation laser technology into dental practice, mainly on a mass scale. outpatient appointment as one of the highly effective methods to improve the quality of dental care.