General - RJ-Laser

RJ-LASER 

Chemotherapy induced 

Mucositis, Palmar Plantar Erythrodysesthesia 

Radiotherapy induced Dermatitis


Recommendations for chemotherapy induced skin disorders 

General 

Oral mucositis (OM) and other chemotherapy induced skin disorders as Palmar Plantar 

Erythrodysesthesia, dermatits are an inevitable complication of radiation therapy (RT), as part 

of gastrointestinal toxicity in chemotherapy and hematopoietic stem cell transplantation (HSCT), 

causing severe morbidity and affecting the patient’s quality of life. 

Palmar plantar erythrodysesthesia (PPE) is a toxicity that can occur to the palms of hands and 

soles of feet with specific chemotherapy treatments. PPE (also known as hand- foot syndrome) 

as a condition marked by pain, swelling, numbness, tingling, or redness of the hands or feet 

and defined as a cutaneous toxicity that manifests with palmar and plantar erythema, edema, , 

scaling, and vesiculation. The incidence of PPE depends on the drug therapy, dosage, and the 

manner in which the drug is administered. 

Duration and severity of OM, especially in higher grades, are critical, as it hampers the cancer 

treatment, affects duration of hospital stay, and to a certain extent, predicts success of 

treatment and complications such as graft-versus-host disease (GVHD) in transplantation 

patients. There is no consensus on a single agent or agents that can be used either 

prophylactically or therapeutically in OM. The frequency of OM varies from 12% in patients 

receiving adjuvant chemotherapy to 80% and 100% in patients undergoing HSCT and RT of 

the orofacial region, respectively.1,2 The art and science of photomedicine, low-level laser 

therapy (LLLT) have become promising and effective tools in prophylactic and therapeutic 

interventions for OM, orofacial pain and PPE. 

Considerable buccal toxicity of radiotherapy and/or chemotherapy in patients with cancer can 

cause patients to become discouraged and can alter their quality of life. In addition, such 

toxicity often necessitates alterations of treatment planning, with grave consequences in term of 

tumor response and even survival (concept of dose-intensity). 

Photomedicine using LLLT is very effective with intra-oral and extra-oral devices in the 

management of OM, based on several reports including randomised control studies. 

Photomedicine is a safe and relatively inexpensive intervention for cancer therapy-induced 

OM. It is envisaged that Photomedicine will soon become part of routine oral supportive care 

in cancer. 

Multinational Association of Supportive Care in Cancer/International Society of Oral 

Oncology (MASCC/ISOO) guidelines of 2004 on cancer supportive care and management 

reported LLLT as a “possible option”. In 2007, MASCC-ISOO ‘evidence-based’ mucositis 

guidelines have upgraded LLLT as a "recommended" method for the prevention of OM during 

bone-marrow transplantation or HSCT. American Cancer Society mentioning the evidence 

behind LLLT as ‘promising’. 

Laser therapy can be used as a stand-alone therapy, as an adjunctive to common treatments 

and it can easily be combined with other therapies and medicaments. 

© RJ-LASER Germany | 1



Mucositis accurs in the following frequency: 

10% with adjuvant chemotherapy 

40% during chemotherapy (curative) 

80% stemcell transplantation (myeloablative chemotherapy) 

100% head and neck tumors and radiation therapy (head in the radiation field) 

Grades of mucositis according to the WHO 

0: normal oral mucosa, no visible changes 

I: erythema, soreness, burning of mucous membrane, no ulceration 

II: Erythema, small ulcers, receiving solid food is not restricted 

III: larger ulcers, the painful mouth allows only liquid/passed food 

IV: Essen und Trinken nicht mehr möglich 

Conventional therapies are limited 

The conventional treatment recommendation is poor, it is usually just limited to oral hygiene, 

pain management, vitamin intake etc.. There is no way to actively treat the condition of the 

mucosa (or skin in case of PPE) itself. 

The best therapeutic results in the laser therapy is achieved when the laser energy and power 

is in the biological optimum. The laser for biostimulation or biomodulation (LLLT) should heal 

and not destroy. The power, energy density, wavelength and duration of therapy (at the target 

tissue) play a vital role and shoulod be in the biological optimum 

. 

Additionally plays modulation (frequency / Hz) a role (so-called laser-resonance therapy). 




For laser therapy the „biological law“ of Arndt/Schulz* is valid: 

strong stimulus paralyses/destroys 

intermediate stimulus blocks 

gentle stimulus improves 

The Arndt-Shultz Law summarizes experiments which measure the physiological response of a 

living organism to a stimulus. It says a small amount of a chemical or electrical or laser or other 

stimulus will increase physiological activity, a large amount of the same stimulus will kill cells of 

the organism, and an intermediate amount will inhibit physiological activity. 

The RJ laser devices are made for application to individual points, reflex therapy and for local 

treatment of small and large areas. RJ laser devices are used for: 

Local therapy (macro system) 

Reflexive therapy (micro system) 

Supply of photon energy (Joule) 

Transfer of information (Hz) 

Successful treatment requires the optimal: 

1. Probe 

2. Applicator head 

3. Wavelength 

4. Power 

5. Energy (J/cm 2 ) and exposure time 

6. Modulation frequency 

* The rule was named after Hugo Paul Friedrich Schulz and Rudolf Arndt. The latter originally formulated it in 1888. 




How to reach the target tissue 

Depending on the individual conditions of the animal the laser beam can reach the target 

tissue or will be absorbed by color/pigmentation or particles. 

The mucosa is perfect to irradiate and the energy of the laser beam can easily reach the cells. 

Wavelength/power/energy 

RJ laser devices offer the recommended wavelengths for bio-modulation. The wavelengths of 

the RJ laser devices are in a very convenient “window” with low absorption levels which offer 

deep penetration. At higher ranges (1000 nm) absorption by water is greater and in lower 

ones, below 500 nm, absorption by red blood coloring and melanin is also more. 

Dispersion in the tissue 

The laser beam is dispersed among the different constituents in the tissue and is reflected. The 

main part of the beam penetrates directly. 




Treatment duration and dosage (energy, J/cm 2 ) 

The patient’s reaction and the symptom being treated should be used as guidelines. As soon as 

an improvement becomes apparent, therapy time can be adjusted and reduced gradually until 

final healing. The power between 150 -500 mW is proven to be optimal for bio-modulation, 

the risk of blocking because of overstimulation is low. 

Start with medium therapy duration 

The goal is to “charge” the cells with photon energy. If therapy is undertaken at high power 

intensity for too long, blockages could prevent the acceleration of the healing process. 

Note: It is better to saturate the cells with photon energy during long therapy duration than 

supplying the total energy within e.g. 2 seconds (as a “flash”). The biological cell system 

needs time to absorb the energy and react to the stimulus. 

Dosage, energy (Joule/cm 2 ) 

The therapeutic dosage is calculated as energy or Joule per cm 2 . Within a certain time the 

required energy for cell stimulation is applied to the specified area/target (Joule/cm 2 ). Simply 

set the energy value in the submenu of your RJ laser. 

Follow the research 

Please pay attention to the results of scientific research which, of course, must be integrated 

into your therapy concept. Generally speaking a dosage of 4-6 Joule per cm 2 or 2-4 Joule per 

point is the recommended stimulus for laser therapy. Still the individual case and target tissue 

should be considered. 




General treatment information (three levels) 

Level 1 – intra-oral, local direct 

Local irradiation, directly to the affected area 

inside the mouth is the most important step. 

The therapy shall lead to 

1. increase of e.g. ATP in the 

mitochondrials 

2. stimulation of the immune system 

3. reduction of pain 

4. acceleration of the regeneration 

5. reduction of inflammation. 

Level 2 - extra-oral, local indirect 

Additionally to level 1 the indirect irradiation 

outside of the mouth (cheeks), can be 

beneficial as well. It depends on the case, 

location and severity of the mucositis. 

Level 3 - reflective, systemic 

Recommendation additional to the 

direct/indirect local therapy: 

1. Irradiation of the arteria carotis or 

tongue, in order to get a systemic 

effect. 

2. Treatment of body/ear points related 

to the treatment area e.g. mouth. 

3. Treatment of reflex zones 




Mucositis 

Palmar Planta Erythrodysesthesia (PPE) 

Condition General Dosage/cm2 

at the target 

Frequency 

Mucositis 

acute 

Mainly local therapy 

4-8 J local 

Daily 

A 

Probe 

Single cw 

Cluster cw 

Additional 

Ear points, Shen Men 

Chronic 

Local and reflexive 

therapy combined with 

basic treatment. 

6-10 J local 

3x/week 

B 

Single cw 

Cluster cw 

Extra-oral 10 J/cm 2 

Palmar Planta 

Erythrodysesthesia 

Dermatitis 

Irradiate directly above 

the damaged area of the 

skin. 

6-10 J local 

3x/week 

B, C 

Cluster cw 

Satellite 

scanner 

Ear points, Shen Men 

Recommendation: Wavelength for a red light source at 633–685 nm, infrared 780– 

810nm; output of diode between 100 - 500mW; dose in the range of 2–3 J/cm2 for 

prophylaxis, not less than 4-8 J/cm2 for therapeutic effect. 




Modulation frequency 

RJ offers a large variety of bio-frequencies and ready Therapy Programs based on these 

frequencies. As an example, the NOGIER frequencies are commonly used since more than 30 

years for diagnosis and therapy. Below there is a brief summary of the NOGIER frequencies, 

which are displayed as: A´ B´ C´ D´ E´ F´ G´ 

Frequency/Hz Disease, part of the body Acupuncture 

A’/292 

Acute illness, cellular level, inflammation, tumors 

Body orifices 

Shu point 

B’/584 

Chronic illness, metabolism, cell nutrition 

Abdomen 

Sedation 

C’/1168 

Circulation, energy transfer, motoric disorder, 

Bones, muscles, joints, extremities Tonification 

D’/2336 

Psychic disorders, fatigue, laterality disorders 

Commissures 

Alarm point 

E’/4672 

Nerve disturbances/pain, neuralgia, neuritides, 

Spinal cord, nerves 

Starting point 

F’/9344 

Depressions, psychic symptoms and causes, 

Bone reconstruction 

Face, subcortex, emotions 

End point 

G’/18688 

Intellectual and psychosomatic disturbances 

Frontal cerebral zone 

Source point 

Regenerating= A+B+F Analgesic= C+D+G, Muscle relaxation= E+G Focus= A´+A´´ 

Apply the NOGIER frequencies directly on the body part and if possible according to the RAC 

pulse reaction. Always apply cw and the frequency additionally for a few 

seconds. 




Ear points (for additional treatment) 

For mucositis: mouth (A), cheeks (F), Shen men 

For PPE/dermatitis: hand/feet (C), Shen men 




Research 

The Prevention of Induced Oral Mucositis with Low-Level Laser Therapy in 

Bone Marrow Transplantation Patients: A Randomized Clinical Trial 

Geisa Badauy Lauria Silva, D.D.S., M.Sc.,1 Elismauro Francisco Mendonc¸a, D.D.S., M.Sc., Ph.D.,2 

Cesar Bariani, M.D.,1 Heliton Spindola Antunes, D.D.S., M.Sc.,3 and Maria Alves Garcia Silva, D.D.S., M.Sc., Ph.D.2 

Abstract 

Background Data and Objective: Patients who have received high doses of 

chemotherapy, either alone or in combination with total body irradiation often cite oral 

mucositis (OM) as the most debilitating side effect. The aim of this study was to investigate the 

clinical effects of low-level laser therapy (LLLT) on the prevention of conditioning-induced OM in 

hematopoietic stem cell transplantation (HSCT). 

Material and Methods: We randomized 42 patients who underwent autologous or 

allogeneic HSCT. A low-level InGaAlP diode laser was used, emitting light at 660 nm, 40mW, 

and 4 J/cm2. An evaluation of OM was carried out using the World Health Organization 

scale. Results and Conclusion: In the LLLT group, 57.1% of patients had an OM grade 0, 9.6% 

had grade 1, and 33.3% had grade 2, whereas in the control group, only 4.8% of patients 

were free of OM (grade 0). 

Results: Our results indicate that the preventive use of LLLT in patients who have undergone 

HSCT is a powerful instrument in reducing OM incidence. 

Severity of Oral Mucositis in Patients Undergoing Hematopoietic Cell 

Transplantation and an Oral Laser Phototherapy Protocol: A Survey of 30 

Patients 

Fernanda de Paula Eduardo, D.D.S., M.S.D., Ph.D.,1 Leticia Bezinelli, D.D.S.,1 

Ana Claudia Luiz, D.D.S., M.S.D.,1 Luciana Correa, D.D.S., M.S.D., Ph.D.,2 

Cristina Vogel, R.N.,1 and Carlos de Paula Eduardo, D.D.S., M.S.D., Ph.D.3 

Abstract 

Background Data and Objective: Oral mucositis (OM) is one of the worst cytotoxic 

effects of chemotherapy and radiotherapy in patients undergoing hematopoietic cell 

transplantation (HCT), and it causes severe morbidity. 

Laser phototherapy has been considered as an alternative therapy for prevention and 

treatment of OM. The aim of this study was to describe the incidence and severity of OM in 

HCT patients subjected to laser phototherapy, and to discuss its effect on the oral mucosa. 

Patients and Methods: Information concerning patient age and gender, type of basic 

disease, conditioning regimen, type of transplant, absence or presence of pain related to the 

oral cavity, OM grade, and adverse reactions or unusual events were collected from 30 

patients undergoing HCT (allogeneic or autologous). These patients were given oral laser 




phototherapy with a InGaAIP laser (660 nm and 40 mW) daily. The data were tabulated and 

their frequency expressed as percentages. 

Results: In the analysis of those with OM, it was observed that 33.4% exhibited grade I, 

40% grade II, 23.3% grade III, and 3.3% grade IV disease. On the most critical post-HCT 

days (D_5 and D_8), it was observed that 63.3% of patients had grade I and 33.3% had 

grade II disease; no patients had grade III or IV disease in this period. This severity of OM was 

similar to that seen in other studies of laser phototherapy and OM. 

Conclusion: The low grades of OM observed in this survey show the beneficial effects of 

laser phototherapy, but randomized clinical trials are necessary to confirm these findings. 

Photomedicine and Laser Surgery 

Vue 27 uber 1 2009 

Low Level Laser Therapy in Management of Chemotherapy- 

Induced Oral Mucositis: Prophylaxis or Treatment 

Gholamreza Esmaeeli Djavid1, Amirhossein Emami2, Leila Ataie-Fashtami3 

Seyed reza Safaeinodehi2, Farzad Merikh-Baiat4, Mohsen Fateh1, Nasrin Zand3 

1Photobiostimulation Research Group, Iranian Center for Medical Laser, Academic Center for Education, Culture, and 

Research (ACECR), Tehran, Iran 

2Assistant Professor of Hematology and Oncology, Valiasr Hospital, Tehran University of Medical Sciences, Tehran, Iran 

3Assistant Professor of Dermatology, Iranian Center for Medical Laser, Academic Center for Education, Culture, and 

Research (ACECR), Tehran, Iran 

4Researcher, Tehran University of Medical Sciences, Tehran, Iran 

Abstract: 

Introduction: Chemotherapy-induced oral mucositis (COM) is a common, debilitating 

complication of cancer therapy. The aims of this study were to evaluate the effect of 

low level laser therapy (LLLT) on prevention of COM in patients with hematologic 

malignancies. 

Methods: Fifty-five patients hospitalized to undergo chemotherapy in Imam Hospital 

were included into the study. These patients were divided into two groups. The oral 

cavity of the patients were illuminated by continues laser beam using a GaAlAs 

laser device with wavelength of 630 nm, power output 30 mW, and dose of 5 J/cm2 

for six days (LLLT group). The patients in the second group underwent placebo 

irradiation (power output equal to zero) with the similar protocol. The severity of 

the COM was clinically evaluated based on WHO grading scale. The patientys’ 

quality of life was assessed before and after the intervention according to EORTC 

QLQ-C30 questionnaire. 

Results: The incidence of COM in LLLT group (31%) was less than the placebo 

group (41%). Mean duration of COM healing was 4.8 and 12 days in LLLT and 

placebo groups, respectively (p=0.03). Xereostomia was significantly less severe in 

LLLT group in comparison with the placebo group (p=0.007). 

Conclusion: Our findings showed that LLLT significantly reduced the incidence of 

oral mucositis of WHO grade 3 and 4 as the most debilitating form of oral mucositis, 

in which oral alimentation is impossible. Also, LLLT could reduce duration of oral 

mucositis, decreased the risk of secondary infection, and accelerated return to normal 

nutrition. 




Use of 660-nm Diode Laser in the Prevention and Treatment of Human Oral 

Mucositis Induced by Radiotherapy and Chemotherapy 

Taı´s Zanin, D.D.S., M.S.,1,2 Fatima Zanin, D.D.S., M.S., Ph.D.,3 Artur Aburad Carvalhosa, D.D.S., Ph.D.,2 

Paulo Henrique de Souza Castro, D.D.S.,2 Marcos Tadeu Pacheco, Ph.D.,3 

Iriana Carla Junqueira Zanin, D.D.S., M.S., Ph.D.,4 and Aldo Brugnera Junior, D.D.S., M.S., Ph.D.3 

Abstract 

Objective: The aim of this multidisciplinary study was to evaluate quantitatively and 

qualitatively the effect of a 660-nm diode laser in the prevention and treatment of human oral 

mucositis (OM) in patients suffering from head and neck cancer who had undergone 

radiotherapy and chemotherapy. 

Background Data: OM is a severe oral lesion resulting from the toxic effects of treatment 

for cancer in the head and neck region. Low-level laser therapy is indicated to prevent and 

treat this oral complication and may be used alone or in association with conventional drug 

treatment, producing pain relief and wound repair. 

Methods: This study included 72 patients with head and neck cancer treated at the Cancer 

Hospital of Mato-Grosso, Brazil, and divided into a control group (C; n¼36) and a laser 

group (L; n¼36). Laser therapy was performed in combination with radiotherapy 

and chemotherapy twice a week using a diode laser (l¼660 nm, power¼30mW, spot 

size¼2 mm, energy¼2 J per point). 

Results: Statistically significant differences were observed between the two groups. Patients in 

group L usually did not present with OM or pain, but all patients in group C presented with 

OM ranging from Level I to III associated with pain. This difference was significant from week 

1 on, increased until week 4 and remained stable up to week 7. Conclusion: Laser therapy 

was effective in preventing and treating oral effects induced by radiotherapy and 

chemotherapy, thus improving the patient’s quality of life. 


Volume 28, Number 2, 2010 

The Prevention of Induced Oral Mucositis with Low-Level Laser Therapy in 

Bone Marrow Transplantation Patients: A Randomized Clinical Trial 

Geisa Badauy Lauria Silva, D.D.S., M.Sc.,1 Elismauro Francisco Mendonc¸a, D.D.S., M.Sc., Ph.D.,2 

Cesar Bariani, M.D.,1 Heliton Spindola Antunes, D.D.S., M.Sc.,3 and Maria Alves Garcia Silva, D.D.S., M.Sc., Ph.D.2 

Abstract 

Background Data and Objective: Patients who have received high doses of 

chemotherapy, either alone or in combination with total body irradiation often cite oral 

mucositis (OM) as the most debilitating side effect. The aim of this study was to investigate the 

clinical effects of low-level laser therapy (LLLT) on the prevention of conditioning-induced OM in 

hematopoietic stem cell transplantation (HSCT). 

Methods: We randomized 42 patients who underwent autologous or allogeneic HSCT. A 

low-level InGaAlP diode laser was used, emitting light at 660 nm, 40mW, and 4 J/cm2. An 

evaluation of OM was carried out using the World Health Organization scale. Results and 




Conclusion: In the LLLT group, 57.1% of patients had an OM grade 0, 9.6% had grade 1, 

and 33.3% had grade 2, whereas in the control group, only 4.8% of patients were free of 

OM (grade 0). 

Results: Our results indicate that the preventive use of LLLT in patients who have undergone 

HSCT is a powerful instrument in reducing OM incidence. 


Volume 29, Number 1, 2011 

LEVEL LASER THERAPY IN TRE PREVENTION AND MANAGEMENT OF ORAL 

MUCOSITIS INDUCED BY CANCER TREATMENTS: EVIDENCE-BASED DATA FROM 

RANDOMIZED STUDIES AND META-ANALYSES 

René-Jean Bensadoun, M.D. 

Professor and Chairman, Radiation Oncology Department, CHU de Poitiers 

Address: BP 577, 86021 - Poitiers Cedex, France , E-mail: rene-jean.bensadoun@chu-poitiers.fr 

ABSTRACT 

We discuss the promising state of the art of Photomedicine for preventative and therapeutic 

usage in Oral Mucositis (OM) due to cancer therapy. 

Recent findings: Photomedicine using LLLT or LED is very effective with intra-oral and extraoral 

devices in the management of OM, based on several reports including randomised control 

studies. A systematic review identified 33 relevant articles which were subjected to metaanalysis 

based on which laser parameters in routine practice are being defined. Meta-analysis 

showed that LLLT reduced risk of OM with relative risk (RR) 2.45 (CI 1.85-3.18), reduced 

duration, severity of OM and reduced number of days with OM (4.38 days, p=0.0009). 

Relative risk was similar between the red (630-670 nm) and infrared (780-830 nm) LLLT. Painrelieving 

effect based on the Cohen scale was at 1.22 (CI 0.19-2,25). 

Conclusion: There is moderate to strong evidence in favour of Photomedicine at optimal 

doses as a safe, relatively inexpensive intervention for cancer therapy-induced OM. It is 

envisaged that Photomedicine will soon become part of routine oral supportive care in cancer. 

Laser in medicine, vol I, issue 1, October 2012 

PPE 

Objective: The aim of this study was to evaluate the usefulness of low-level laser therapy (LLLT) 

for the control of painful stomatitis in patients with hand-foot-and-mouth disease (HFMD). 

Background Data: LLLT has been successfully applied to various painful oral mucosal 

diseases, although there have been few reports on LLLT for HFMD patients. 

Material and Methods: Through a randomized double-blind placebo controlled trial, the 

painful period of HFMD stomatitis was compared between the LLLT group (n=11) and the 

placebo LLLT one (n=9), which had similar clinical backgrounds. The LLLT parameters supplied 




were as follows: wavelength of 830 nm, power of 30 mW, frequency of 30 Hz, and energy 

output of 1.1 J/cm2. Acceptability and safety of the treatment were also evaluated. 

Results: The painful period was shorter in the LLLT group (4.0 +/- 1.3 days) than in the 

placebo LLLT one (6.7 +/- 1.6 days) with a statistically significant difference (p



Recommended probes 

Probe type 

Application Specification 

Points small 

areas 

Single probe cw 

150 mW/638 nm (used for PDT as well) 

2 Joule/13 sec. 

500 mW/810 nm/2 Joule/4 sec. 

Points small 

areas 

Dark hair/skin 

Deep bone 

penetration 

Large areas 

Hairless skin 

Large areas 

Dark hair/skin 

Deep bone 

penetration 

Single probe sp (superpulse) 

90 W/904 nm, pulse width 200 nsec. 

2 Joule/12,3 sec. at 9000 Hz 

Cluster probe cw 

8x55 mW/785 nm + 4x40 mW/650 

nm 

2 Joule/3,2 sec. 

Single probe sp (superpulse) 

5x30 W/904 nm, pulse width 200 nsec. 

2 Joule/7,4 sec. at 9000 Hz 

Small, medium, 

large areas 

Hairless skin 

Large area scanner cw 

150 mW/638 nm + 500 mW/810 nm 

2 Joule/3 sec. 




Applicator heads 

Note: The selection of the applicator depends on the fur type and size of the area. 




REIMERS & JANSSEN GmbH 

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79183 Waldkirch, Germany 

Tel. +49-7681-4934149 Fax +49-7681-4934150 

service@rj-laser.com 

www.rj-laser.com 

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General - RJ-Laser

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