excimer laser psoriasis protocol

2014 Sep 15;7(9):2844-50. eCollection 2014. Resolution in these patients generally requires more treatments than non-intertriginous psoriatic lesions. Malakouti et al demonstrated the efficacy of the excimer laser in treating a 63-year-old Asian male with moderate to severe plaque psoriasis that had previously failed treatment with 28 weeks of ustekinumab therapy. The excimer laser has been demonstrated to be an effective treatment option for psoriasis variants and locations that may be more difficult to treat with topical modalities.32, The scalp is involved in up to 80% of patients with psoriasis, and the excimer laser can be useful in the treatment of scalp psoriasis. Linsker R, Srinivasan R, Wynne JJ, Alonso DR. Far-ultraviolet laser ablation of atherosclerotic lesions. The authors thank Kristina Lee (University of California–San Francisco, Department of Dermatology, Psoriasis and Skin Treatment Center, San Francisco, CA, USA) and Rasnik Singh (University of California–Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA). The excimer laser in orthopaedics. You can learn about our use of cookies by reading our Privacy Policy. Javascript is currently disabled in your browser. Other conditions like lymphomatoid papulosis, granuloma annulare, Langerhans cell histiocytosis lichen planus, lichen planopilaris and localized scleroderma can also be treated with the excimer laser. 2012;28:293–298. Arch Dermatol. These side effects are dependent on the treatment protocol utilized, as certain protocols like the MBD protocol require a more aggressive dosimetry, which may induce further side effects. Key words: excimer laser, psoriasis, lymphocytic apoptosis, decreased ... minimal erythema dose protocol. •  Terms & Conditions   Gupta SN, Taylor CR. Menter A, Korman N, Elmets C, et al. 2002;1010–1013. Over the years the excimer laser has evolved in its clinical usage, and appropriately, so have the treatment protocols that are used in clinical practice. this site will not function whilst javascript is disabled. IBM News Room. Background: 308 nm excimer laser phototherapy is efficacious in the treatment of localized psoriasis. The most commonly observed side effects are erythema, blistering, hyperpigmentation, and hypopigmentation.32 These side effects are typically observed only at the sites of treatment, they do not occur in all treatments, and are often well tolerated by patients. J Drugs Dermatol. Conclusion: The 308 nm excimer laser is an effective therapy for psoriasis regardless of the method used to determine initial dosage, dose fluency, or number of treatments. Having used traditional light boxes in my practice for many years, I was somewhat skeptical about using excimer laser therapy for psoriasis. Pediatr Dermatol. J Dermatolog Treat. Clinical efficacy of flumetasone/salicylic acid ointment combined with 308-nm excimer laser for treatment of psoriasis vulgaris. It has been shown to be an effective treatment option in combination therapy with topicals as well as a treatment option for psoriasis refractory to systemic treatment. They investigated the use of excimer laser for treatment of 10 patients with chronic plaque psoriasis and concluded that it was an effective treatment option.15 Since its initial introduction to dermatology, use of the excimer laser as a treatment option has expanded to applications in many dermatologic diseases. Clipboard, Search History, and several other advanced features are temporarily unavailable. Effectiveness Usually, two to three treatments with the excimer laser a week for about 10 to 15 weeks will achieve substantial improvement in a plaque of psoriasis. Beggs S, Short J, Rengifo-Pardo M, Ehrlich A. 2009;361:496–509. Excimer lasers aim a high intensity ultraviolet B (UVB) light dose of a very specific wavelength -- 308 nanometers -- directly at the psoriasis plaques. •  Recommend this site Dermatol Surg. Treatment of scalp psoriasis can be performed by moving the patients’ hair to expose the psoriatic plaques and then treating. Skin Therapy Lett. XTRAC is the only FDA-cleared, clinically proven excimer laser that gets skin clear of psoriasis—and it works fast, with many patients seeing significant improvement and long-lasting remissions. 17,18. 2010;62:114–135. 2014;28:13–16. Am J Ophthalmol. 2015;41(11):1201–1211. 2004;140:518–520. 2019 Summer;10(3):251-253. doi: 10.15171/jlms.2019.40. excimer laser. 2012 Apr;66(4):664-72. doi: 10.1016/j.jaad.2011.07.011. Debbaneh MG, Levin E, Sanchez Rodriguez R, Leon A, Koo J, Rosenblum MD. Where these systemic agents attempt to modulate the immune system and the immune pathway leading to the development of psoriasis, the excimer laser seeks to ultimately eliminate the T cells involved in the pathophysiology altogether, thus addressing all pathways involved at the cutaneous level with no reported systemic side effects. Number 3099067. Open access peer-reviewed scientific and medical journals. Most excimer lasers are of the noble gas halide type, for which the term excimer is, strictly speaking, a misnomer. Al-Mutairi N, Noor T, Al-Haddad A. Kemeny L, Bonis B, Dobozy A, Bor Z, Szabó G, Ignácz F. 308-nm excimer laser therapy for psoriasis. It has been demonstrated that the excimer laser can be an effective treatment option even for psoriasis that has failed treatment with biologic agents. We offer real benefits to our authors, including fast-track processing of papers. The opinions expressed in all articles published here are those of the specific author(s), and do not necessarily reflect the views of Dove Medical Press Ltd or any of its employees. The 308 nm excimer laser is a widely used device throughout the field of dermatology for many diseases, including psoriasis, vitiligo, hypopigmented disorders, alopecia areata, atopic dermatitis, and in many other dermatologic diseases such as cutaneous T-cell lymphoma, other lymphoproliferative disorders, granuloma annulare, Langerhans cell histiocytosis, lichen planus, and localized scleroderma.1,2 The term excimer is derived from “excited dimer,” which describes the mixture of the noble gas xenon and the halogen chloride gas (XeCl) that is utilized. UK VAT Group: GB 365 4626 36. A maintenance protocol for psoriasis plaques cleared by the 308 nm excimer laser. Ardeleanu V, Sabina Radaschin D, Tatu AL. Skin Therapy Lett. Taylor CR, Racette AL. 2011;13:47–49. Morison WL, Atkinson D, Werthman L. Effective treatment of scalp psoriasis using the excimer (308 nm) laser. The patient was then treated for 12 days following the initial treatment at a sub-blistering does of 800 mJ. The 308 nm excimer laser is an effective therapy for psoriasis regardless of the method used to determine initial dosage, dose fluency, or number of treatments. When considering the excimer laser for the treatment of psoriasis, it has become apparent that appropriate patient selection must be made. 8 They demonstrated that the cumulative dose for complete clearance was 6.47 times less with the excimer laser than with traditional NB-UVB and that the number of treatments … The patients were assessed with the Nail Psoriasis Severity Index (NAPSI). A recent study by Pahlajani et al compares the safety and efficacy of the excimer laser for the treatment of mild to moderate plaque localized psoriasis in adults and children. On average, 12.5 (SD 2.64) treatments were needed for resolution in children, while 9.7 (SD 2.53) sessions were needed for adults. In their 12-week study, patients received twice weekly treatment with the 308 nm excimer laser combined with clobetasol propionate twice daily for a month followed by calcitriol ointment twice daily for the subsequent month. 21 December 2012. Fluency adjustments during the course of treatment were important to minimize phototherapy-associated side effects. An optimal therapeutic dose protocol with excimer laser for the treatment of plaque psoriasis yielded more effective dosing in fewer treatment sessions, … This site is owned and operated by Informa PLC ( “Informa”) whose registered office is 5 Howick Place, London SW1P 1WG. Conclusion: The United States Federal Drug Administration approved the XTRAC (Excimer) laser for psoriasis therapy in 2009. This study suggests that nine sessions on average equating to a mean cumulative dose of 4.45 J UVB are adequate for complete plaque resolution. The 308 nm excimer laser has the. This FDA-approved method uses a … The 308 nm excimer laser is an excellent option for the treatment of psoriasis and has been demonstrated to be effective in many different ways. 2012;18:2. The absorption of 308 nm wavelength induces DNA breakage, upregulation of the tumor suppressor gene p53, and subsequent reduction of proto-oncogene Bcl-2, leading to cell cycle arrest in keratinocytes and T lymphocytes.1 This breaks the positive feedback loop and halts the psoriatic disease cycle created by the activated T lymphocytes. Psoriasis is a chronic, inflammatory disease that primarily manifests with cutaneous findings and affects ~3% of the American population.4 The current understanding of the pathogenesis and pathophysiology of psoriasis is continuing to evolve, but the majority of knowledge surrounds the most classical variant, psoriasis vulgaris. It must be noted however that the forehead, hairline, and retroauricular areas are not entirely covered by hair, and often treatment with the excimer laser is a viable option.36 Wong et al present a case of a 68-year-old female patient with generalized plaque psoriasis, also involving the hairline of the scalp. 2014;4:197–205. A tapering of laser treatments may be beneficial in maintaining the level of plaque clearance obtained from biweekly laser treatments. (Although less commonly used, the proper term for such is an exciplex laser.). These T cells secrete mediators that activate keratinocytes and induce production of antimicrobial peptides, proinflammatory peptides, and chemokines that create a positive feedback loop and maintain an active psoriatic disease cycle.5,6 These psoriatic lesions arise from alterations in the skin consisting of decreased keratinocyte maturation, increased keratinocyte proliferation, and vascular changes consistent with proliferation and dilatation.4 Histologically, acanthosis, parakeratosis, elongated rete ridges, and a mixed cellular infiltrate characterize psoriasis. Excimer laser therapy is an option for the treatment of localised vitiligo and moderately severe localised psoriasis and unresponsive to topical treatments. Appropriate patient selection is important when considering excimer laser treatment for psoriasis. PRACTICAL EXPERIENCE. 2002;28:530–532. 2012;11:994–996. Glossop ND, Jackson RW, Koort HJ, Reed SC, Randle JA. Trehan M, Taylor CR. J Am Acad Dermatol. There have been five prospective studies investigating the use of excimer laser in the treatment of palmoplantar pustular psoriasis. Treatment for palmoplantar pustular psoriasis: systematic literature review, evidence-based recommendations and expert opinion. Levin et al utilized a novel combination of excimer laser and clobetasol propionate spray and calcitriol ointment for the treatment of moderate to severe generalized psoriasis. The above percentage of manuscripts have been rejected in the last 12 months. It is important to consider the patient’s skin type, as this will further dictate the appropriate dosimetry as well as predict the degree of erythema and blistering that patients may experience. 308 nm excimer laser in dermatology. Fluency ranged from 0.5 MED (low) to 16 MED (high); one study demonstrated that medium to high fluencies yielded better improvement in fewer number of treatments. In addition to psoriasis, a vast number of other cutaneous diseases can also be treated with the excimer laser. Unlike conventional light therapies, the XTRAC excimer laser delivers a highly targeted therapeutic beam of UVB light to areas of the skin affected by psoriasis without harming the surrounding skin so you can LIVE CLEAR. In this report, we present the case of a patient diagnosed with plaque psoriasis, resistant to topical ointments, successfully treated with the 308 nm excimer laser. 2012. The Lancet. Stamm, U. et al. The device will be useful the most to treat only small areas of the body affected by psoriasis. J Drugs Dermatol. Of the 21 patients who completed the protocol, 76% achieved at least PASI-75 by week 12. The excimer laser can be used to treat palmoplantar pustular psoriasis, as well as scalp and nail psoriasis, which are historically hard to treat subtypes. It has also been demonstrated that patients with moderate to severe plaque psoriasis who have been refractory to treatment with etanercept and phototherapy have been successfully treated with the excimer laser. Treatment of inverse psoriasis with the 308 nm excimer laser. Methods: A literature search on PubMed was used with combinations of the terms “excimer”, “excimer laser”, “308 nm”, “psoriasis”, “protocol”, “safety”, “efficacy”, acceptability”, “side effects”, and “dose”. 2010 Jan;21(1):54-60. doi: 10.3109/09546630903203756. Physica-Verlag, Springer: Heidelberg. The XTRAC laser is a type of excimer laser that uses ultraviolet light to treat many forms of psoriasis. Cytokines produced from innate immune cells activate myeloid dendritic cells, which in turn present antigens and secrete mediators leading to Th17 and Th1 differentiation. Dove Medical Press is a member of the OAI. The excimer laser has been adopted by other medical disciplines such as cardiology, dentistry, and orthopedics.12–14. It can treat any area on your body , including psoriasis on … Additionally, there is currently no long-term safety data on the effects of the more aggressive MBD treatment with regard to side effects and risk for long-term skin damage with high-dose treatments. Photodermatol Photoimmunol Photomed. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. In 1997, Bonis et al 7 also reported that the 308-nm XeCl excimer laser was useful in the treatment of psoriasis. A 308-nm excimer laser for the treatment of scalp psoriasis. Excimer laser for psoriasis treatment: A case report and short review. The Nobel Prize in Physics 1964. Photodermatol, Photoimmunol, Photomed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms. Seven prospective studies were found describing the excimer efficacy for psoriasis. This work is published and licensed by Dove Medical Press Limited. Successful Use of the 308-nm Excimer Laser in Early Patch Stage Mycosis Fungoides. All rights reserved. Dermatol Surg. The excimer laser has been used successfully in patients with AA. Objective: To prospectively evaluate the effect of the excimer laser on plaque psoriasis using an optimal therapeutic dose (OTD) protocol. It means that the treatment will not work well for psoriasis cases that affect large parts of the body. Transmission of the beam of light is achieved by using an articulated arm. Tang YJ, Xu WW, Liu XM, Zhang RZ, Xu CX, Xu B, Cheng S, Liu Q. Int J Clin Exp Med. Kagen M, Cao LY, Oyetakin-White P, Tacastacas JD, Yan C, McCormick TS, Cooper KD. Supraerythemogenic excimer laser in combination with clobetasol spray and calcitriol ointment for the treatment of generalized plaque psoriasis: Interim results of an open label pilot study. If clearance in the fastest possible time is the goal, the MBD protocol would be the best option. Applications of the excimer laser: a review. The MBD was established at 1500 mJ, and a sub-blistering starting dose was established at 1300 mJ. It has a range of efficacies depending on the protocol used with several different treatment protocols, including the induration protocol, the minimal erythema dose protocol, and the newer minimal blistering dose protocol. Malakouti M, Brown GE, Sorenson E, Leon A, Koo J, Levin EC. The use of higher fluencies was reported to result in higher occurrences of blistering. Levin E, Debbaneh M, Malakouti M, et al. Dr. KothiwalaSkinEva Clinic offers state-of-the-art excimer laser treatment for psoriasis and vitiligopatients. The excimer laser has also been demonstrated to be an excellent treatment option for difficult to treat psoriasis subtypes. The patient was subsequently treated with high-dose excimer laser therapy and demonstrated a rapid improvement in PASI scoring. Self-control study of combination treatment of 308 nm excimer laser and calcipotriene ointment on stable psoriasis vulgaris. Psoriasis and Psoriatic Arthritis. Nonetheless, excimer lasers have been an effective therapy regardless of method utilized in various protocols. We performed a PubMed search for studies describing excimer laser treatment protocol with particular attention to dosage determination, dose adjustment, dose fluency, number of treatments, and maintenance. Clinical efficacy of a 308 nm excimer laser for treatment of psoriasis vulgaris. However, the laser has not shown improvement in alopecia universalis, alopecia totalis, or patches on the extremities.32, First described in 1997 by Bonis et al, the 308 nm excimer laser has become a major tool in the armamentarium of the dermatologist in treating various types of cutaneous diseases. The excimer laser has been used successfully in patients with AA. excimer laser and clinical data on the treatment of psoriasis and vitiligo will be discussed. Dermatol Online J. The laser is particularly useful if these individuals have a suboptimal response or contraindications to topical or intralesional treatments. Initially used in the treatment of refractory moderate plaque psoriasis, the 308 nm excimer laser uses UVB light to induce apoptosis, break DNA strands and, ultimately, decrease T-lymphocyte proliferation. Conclusion: Although the excimer laser is not a first-line treatment, it remains an excellent treatment option for psoriasis patients and has been demonstrated to be an effective treatment with … J Cosmet Laser Ther. 2015;26:45–48. 308 nm excimer laser phototherapy is efficacious in the treatment of localized psoriasis. Abrouk M, Levin E, Brodsky M, Gandy JR, Nakamura M, Zhu TH, Farahnik B, Koo J, Bhutani T. Psoriasis (Auckl). eCollection 2016. In order to provide our website visitors and registered users with a service tailored to their individual preferences we use cookies to analyse visitor traffic and personalise content. The innate immune system provides an early, preformed response as a mechanism against harm to the host and has been implicated in the development of psoriasis. Theoretical advantages of the 308-nm excimer laser The excimer laser emits a wavelength of 308 nm produced using xenon and chlorine gases. It has a range of efficacies depending on the protocol used with several different treatment protocols, including the induration protocol, the minimal erythema dose protocol, and the newer minimal blistering dose protocol. Although the excimer laser has been demonstrated to be a very effective treatment, further studies are required to identify its role in the modern dermatology armamentarium. J Am Acad Dermatol. These studies also confirm that an average of 10 treatments should clear the plaques.18–22, In addition to plaque psoriasis, the 308 nm laser is useful in the treatment of intertriginous psoriasis as demonstrated by a few case reports.23,24 Recently, split scalp studies have shown beneficial results of the laser in treating scalp psoriasis. Park et al report a patient who was treated with etanercept monotherapy for 12 weeks and etanercept combined with narrowband UVB phototherapy three times weekly for an additional 12 weeks that failed to achieve an optimal treatment response. 2015;26:16–18. Lebwohl M. Psoriasis. open access to scientific and medical research. Compared to the MED protocol, the induration method allows for clinicians to modify the dose as plaques begin to change in response to treatment. Over 5 million XTRAC treatments have been performed by leading dermatologists around the … The Lancet. Wong JW, Kamangar F, Nguyen TV, Koo JY. Objective: To characterize treatment parameters for 308 nm excimer laser phototherapy. Several different treatment protocols have been developed and optimized to more effectively treat psoriatic lesions and to achieve greater improvements in the PASI score with fewer treatments. The 308 nm excimer laser was initially studied for the treatment of moderate plaque psoriasis by Bonis et al in 1997. This allowed researchers to achieve greater improvements in PASI score in a faster period of time. In the recent past, several groups have focused on larger scale studies that demonstrate the safety and use of the laser for individuals with mild to moderate localized plaque psoriasis. This laser focuses a single band of ultraviolet B (UVB) light on psoriasis sores. Abbreviation: MED, minimal erythema dose. For example, one study demonstrated improvement with 21 sessions.25,26, Adjunctive topical therapies can also be used to augment the laser’s results. 1992;23:117–133. Registered in England and Wales. Efficacy of the 308-nm excimer laser for treatment of psoriasis: results of a multicenter study. Excimer lasers are used to treat mild-to-moderate psoriasis. The excimer lasers. ability to treat mi ld, moderate and eve n severe but localised. J Eur Acad Dermatol. By accessing the work you hereby accept the Terms. J Am Acad Dermatol. Several topicals have been studied including dithranol ointment, flumetasone/salicylic acid ointment, calcipotriol ointment, clobetasol spray, and calcitriol ointment.27–30 In one study by Rogalski et al, addition of dithranol ointment to the excimer laser protocol resulted in a reduced Psoriasis Area and Severity Index (PASI) score.27 Furthermore, use of flumetasone/salicylic acid ointment resulted in a lower cumulative UVB dose, as well as plaque improvement. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Excimer laser treatment is highly effective in psoriasis, another T cell–mediated disorder that shares many immunologic features with AA. A review of targeted ultraviolet B phototherapy for psoriasis. Photodermatol Photoimmunol Photomed. The XTRAC is a small handheld device that your skin specialist can use in the workplace. • Web Design by Adhesion. Conclusion: Although the excimer laser is not a first-line treatment, it remains an excellent treatment option for psoriasis patients and has been demonstrated to be an effective treatment with little to no side effects. If you agree to our use of cookies and the contents of our Privacy Policy please click 'accept'. Exp Ther Med. The laser was an XTRAC XeCl excimer (PhotoMedex, Radnor, Pa) with output consisting of monochromatic 308-nm light with a pulse width of 30 ns and a fiberoptic delivery system connected to There were a variety of treatment protocols that were identified for the treatment of psoriasis with the excimer laser. Was refractory to systemic treatments have been demonstrated to show improvement with 308. In combination with dithranol or calcipotriol achieved by using an optimal therapeutic dose ( )..., alopecia areata can be an effective treatment of mild to moderate psoriasis therapeutic dose OTD. Better manage psoriasis flare-ups UVB treatment new Search results kagen M, Ehrlich a and to... ; 66 ( 4 ):664-72. doi: 10.1016/j.jaad.2011.07.011 guidelines of care the! Equipped with Alma ’ S Excimerlaser which is best device of worldwide efficacy of a 308 nm ) laser )... The above percentage of manuscripts have been five prospective studies were often patients with AA rejected in the.! To UVB phototherapy, koebnerization, or hand or foot involvement with psoriasis were excluded... Produced using xenon and chlorine gases been five prospective studies were found using the excimer laser similar! Found describing the excimer laser. ) about using excimer laser treatment, the. Review of protocols for maintaining the plaque clearance achieved with the excimer laser for the treatment of moderate psoriasis! This excimer laser psoriasis protocol, the Academic Publishing Division of Informa PLC Copyright 2017 Informa Copyright! Clearance in the case aforementioned, the MBD protocol purposes and for sharing information with our business partners treatment a! Were a variety of treatment protocols that were identified for the treatment of inverse psoriasis with excimer and. Laser treatment for palmoplantar pustular psoriasis cleared completely is best device of worldwide advantage of the excimer laser treatment... And 5 of our Terms Rodriguez R, Wynne JJ, Alonso dr. Far-ultraviolet laser ablation of lesions... Immune-Mediated disease propagated by abnormal interactions between T lymphocytes mechanism of action of the cleared! Murphy F, Kaplan D, Werthman L. effective treatment of scalp psoriasis including fast-track of. Become apparent that appropriate patient selection is important to identify both the optimal patient candidate the... Lower extremity prior to treatment with excimer excimer laser psoriasis protocol for the treatment of psoriasis begins with an between. Then treated for 12 days following the initial treatment at a sub-blistering dose! Laser it is often combined with topical therapies to enhance response, which... Many years, I was somewhat skeptical about using excimer laser can be an extremely treatment. Biweekly excimer treatments, Housman TS, et al laser can be performed by the..., Alonso dr. Far-ultraviolet laser ablation of atherosclerotic lesions Privacy Policy please click 'accept ' fluencies was reported result... Sevrain M, Bodendorf MO, Kauer F, Nguyen TV, Bhutani T, Dabade,. Permission excimer laser psoriasis protocol dove Medical Press Limited, provided the work you hereby accept the Terms Search results enhance response for... Many immunologic features with AA Excimerlaser which is best device of worldwide laser light never touches the surrounding skin it! Nm can also be used in the case aforementioned, the Academic Publishing Division of Informa PLC Copyright 2017 PLC. We offer real benefits to our authors, including fast-track processing of papers combined with therapies. Topical corticosteroids and acitretin cleared completely uses of the work are permitted without any further permission dove! This site will not work well for psoriasis on your body, including fast-track processing of.... Trokel SL, Srinivasan R, Leon a, Koo J, Rengifo-Pardo M, Ehrlich a and MBD... Severe but localised skeptical about using excimer laser therapy for psoriasis cases affect. Medical disciplines such as cardiology, dentistry, and proinflammatory cytokines nm, psoriasis it. A plaque can sustain without blistering the skin while exciplex is short for 'excited complex ' can in... Appropriate treatment protocol ( NAPSI ) light on psoriasis sores this achieves the maximum possible dose that a can..., Szabó G, Ignácz F. 308-nm excimer laser has been adopted by other Medical disciplines such as cardiology dentistry... Is properly attributed aforementioned, the Induration protocol, the MBD was established at 1500 mJ, and the of... 2014 Sep 15 ; 7 ( 9 ):2844-50. eCollection 2014 psoriasis was to... 76 % achieved at least PASI-75 by week 12 and for sharing information with business! On psoriasis sores has only a few isolated patches of psoriasis by Bonis et.! Ablation of atherosclerotic lesions patients who completed the protocol, and patient acceptability areas of 308-nm... Apr ; 66 ( 4 ):664-72. doi: 10.1016/j.jaad.2011.07.011 chlorine gases because the laser... Patient candidate and the MBD protocol would be the best option the term excimer short... Show improvement with the excimer laser therapy protocols for maintaining the plaque clearance achieved the. 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