Thermal damage and time of excision of micro and super pulsed diode lasers

Abstract

Diode lasers are portable, accessible, efficient and reliable surgical units for performing surgeries and soft tissue biopsies of the oral cavity. The newer units are equipped with micro and super pulsed technologies and systems that allow the selection of different usage parameters in terms of emission mode, duty cycle, power and pulse duration. It is, however, not known which parameters or types of diode lasers produce the most intact tissue samples in the best possible surgical time. The main objective of this ex vivo study was to compare the thermal damage and the excision time of different parameters of the micro pulsed diode laser and the super pulsed diode laser. The secondary objectives were: 1) to provide practical recommendations for performing surgical excisions with diode lasers; 2) to examine possible correlations between the area and the depth of the thermal damage, as well as between the time of excision and the thermal damage. Ten groups of ten swine tongue specimens were excised (8 mm in diameter) using a surgical blade (control group: G1); micro pulsed diode laser in different emission modes, duty cycles, average power, peak power and pulse duration (G2 - 9); and the new super pulsed diode laser (G10) with the smallest single parameter recommended by the manufacturer (average power = 3.2W, peak power = 80 W, pulse duration from 10 μs to 100 ms). The wavelength of both was 940 nm. All parameters were previously measured with the power meter and activated disposable tips were discarded right after each biopsy. The area and the histological depth of the thermal damage were quantified using the NIS-Element Basic Research software (Nikon Instruments Inc), while the excision time was measured between the clamping until the total excision of the lesion. Kruskal-Wallis and Dunn's multiple comparison tests with Bonferroni correction were applied to compare the area and depth of thermal damage, as well as the time of excision between the groups. Correlations between area and depth of thermal damage and between excision time and thermal damage were examined using Spearman's nonparametric correlation coefficient. The level of significance was set at 5%. In the experimental groups (G2 - G10), the total area of thermal damage observed was smaller in the G3 group (continuous mode, average power = 1.5W; median = 0.91 mm2 ; p = 0.009). All other groups had thermal damage areas larger than 1 mm2 with G7 (pulsed mode, duty cycle = 33%, average power = 1.5W, peak = 5.4W and pulse duration of 100 μs) and G9 (pulsed mode, duty cycle = 50%, average power = 1.5W, peak = 3.6W and pulse duration = 1 ms) producing the largest damage areas (median 1.93 and 1.97 mm2 , respectively). In the multiple comparison, controlling the level of global significance, G3 presented a median area of thermal damage significantly smaller than those of G7 (p = 0.013) and G9 (p = 0.036). There were no statistically significant differences in the depth of thermal damage between the groups (p = 0.12). The median excision times of G1 (scalpel) and G10 (super pulsed) were significantly shorter than those found in the micro pulsed diode laser groups (G1 = 50; G10 = 69; G2 to G9 ranged from 142 to 238 seconds; p < 0.001). There was a direct correlation between the depth and area of thermal damage, but no correlation was found between the excision time and thermal damage. The use of the micro pulsed diode laser in continuous mode with average power = 1.5 W produced biopsies with the smallest area of thermal damage and greater tissue integrity, while the use of the super pulsed diode laser (average power = 3.2W, peak power = 80W, pulse duration from 10 μs to 100 ms) allowed faster excisions. Area and depth of thermal damage correlated directly. In clinical practice, the micro pulsed diode laser should be considered in continuous mode, at 1.5 W output power with 1.8 W peak power as the best option when aiming to achieve maximum tissue integrity. Whereas the use of super pulsed diode laser with output power = 3.2W, peak power = 80W, pulse duration from 10 μs to 100 ms, produced the best relationship between thermal damage and excision time, and is recommended when practical necessity requires rapid excisions with reasonable tissue integrity. The use of micro pulsed diode laser in pulsed emission mode with high peak power and long pulse duration should be avoided when performing oral biopsies so that tissue integrity is not compromised and hinders the histopathological analysis of the lesions.