Lymphatic drainage using low level lasers

Lymphatic drainage using low level lasers

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  INFRARED DIODE LASERTHERAPY-INDUCED LYMPHATIC DRAINAGE FOR INFLAMMATION IN THE HEAD AND NECK Luciana Almeida-Lopes1, Attilio Lopes2, Jan Tunér3 and R Glen Calderhead4 1: Collaborating Researcher, ElectroThermoPhotoTherapy Laboratory – UFSCar – Brazil; 2: Department of Oral Pathology, College of Dentistry, University Camilo Castelo Branco, São Paulo, Brazil; 3: Private Dental Clinic, Grängesberg, Sweden; and 4: LG Biomedical, Tochigi and Japan Phototherapy Laboratory, Tokyo, Japan Inflammation of many different aetiologies is a condition affecting almost 100% of all patients presenting at dental clinics, and the complete management of inflammation is often extremely important before any orth- odontic surgery can be carried out. The lymphatic system is one of the body’s main lines of defence against in- flammation, with the lymph nodes playing an extremely major role. laser therapy, or LLLT, has become much more common in dental offices, and is associated with pain attenuation, wound healing and anti-inflammatory properties. The last of these is mediated amongst others by the effect of LLLT on the lymphatic system, which has been shown to enhance lymphatic drainage concomitantly with increasing local blood flow to the treated area. Infected areas and those with viral contamination have been suggested as contraindications for laser ther- apy. The possibility of treating these difficult-to-manage entities through laser therapy-accelerated drainage of theaffectedlymphaticsoffersanotherapproach.Althoughlymphaticdrainageisfrequentlyusedintheclinical setting, its application in dentistry is less common than it should be. An illustrated review of the lymphatic sys- tem of the head and neck is presented, with relevance to the use of infrared diode laser therapy in inducing lym- phatic drainage in the management of inflammation associated with acute infectious processes such as pericoronitis, endodontic abscesses, alveolitis and herpes. A case report is presented illustrating the success of this therapeutic approach for labial herpes simplex. Infrared diode laser therapy-mediated lymphatic drainage offers an interesting and efficacious approach in the management of infectious and contaminated areas, with- out actually irradiating the areas themselves. Key words: Lymphatic drainage, lymph nodes, endodontic disease, infrared laser therapy, pericoronitis, alveolitis, herpes simplex, laser dentistry Introduction The therapeutic laser has been used since the 1980’s in cases of inflammation, acting as a mediator in these pro- cesses, activating the lymphatic flow in the irradiated re- gion(1-5) in addition to stimulating the local autoim- mune system of the patient.(6-8) Because of these proper- ties, laser therapy has been successfully indicated for lymphatic drainage in cases of inflammation in both acute (exudative inflammation) and chronic (prolifer- ative inflammation) cases. The present study reviews the localization of the main palpable lymph nodes in the head and neck, the function of each of the lymph node networks, and presents a technique for the treatment of cases of inflammation through the lymphatic drainage stimulated by the application of laser therapy. The lymphatic system The lymphatic system consists of well-differentiated tis- sue groups which are ultrastructurally distinct and widely spread, ‘Lymph’ comes from the Greek via the Latin ‘lympha’ and means ‘clear water’, which is what the Ancient anatomists found during dissection in what they believed were part of the venous system. The com- plex system of lymphatic vessels has several functions. It drains excess exvasated extracellular fluids back into the blood circulation, is an important component of the scavenging and homeostatic system, and a very impor- tant component of the autoimmune system as part the first line of defence of the body against viral or bacterial attack. The lymphatic system not only acts as a filtration system to trap and then destroy cellular debris from the vascular system and connective tissue, it is also the main repository and ‘superhighway’ for the various types of lymphocytes to enable them to be recruited to any area of the body where they are needed. ORIGINAL ARTICLES Addressee for Correspondence: Luciana Almeida-Lopes DDS PhD. Rua Tibães, 22-Jd. São Bento, CEP 02525.030 Sao Pãulo, Brazil e-mail: lal@apcd.org.br Manuscript received: December 2004 Accepted for publication: February 2005 © 2005 JMLL Ltd. Laser Therapy 14.2: 67-74 67
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  The lymph vesselsstart as closed end microvessels which gradually join up, and enlarge as they do so to form the main vessels that finally transfer the collected lymph back into the blood vascular system at the left subclavicular vein. The lymph vessels of the extremities and trunk drain upwards against gravity using a semi- passive propulsion method, but those of the head and neck that are of particular interest in the current article drain downwards with gravity. Along the paths of the lymphatic vessels are found clusters of circumscribed masses of differentiated tissue, the lymph nodes. These are roundish, encapsulated structures, with an outer cortex surrounding an inner medulla, and are considered secondary lymphoid or- gans.(9) The cortex is packed with lymphocytes, and the medulla contains the ‘medullar cords’, cord-like masses of T- and B- lymphocytes and plasma cells. The B-lym- phocytes are related to humoral immunity, are mostly of bone marrow origin, and are found mainly in the cor- tical follicles, whereas the T-lymphocytes are related to cellular immunity, are mainly of thymus origin, and are found in the paracortical and medullar areas.(10) Lymph nodes are also storage points for macrophage cells, par- ticularly in the medullar area. Normal lymph nodes are about the size of a pea; they are painless to palpation, unruffled, movable and of a soft consistency. Occasionally, in the role of lymph nodes as biolog- ical filters, waste material builds up in a node or group of lymph nodes, and they can succumb to the infection they are designed to fight. The lymph vessels become inflamed (lymphangitis) followed by inflammation of the nodes themselves (lymphadenitis), and in serious cases the lymph flow is obstructed and builds up behind the affected nodes (lymphoedema). These processes pro- duces swelling and pain, with the nodes themselves be- coming hard, swollen and often severely painfully palpable. This is where low incident levels of laser en- ergy have proved extremely useful in controlling the in- flammatory process, recruiting scavenger cells such as neutrophils and macrophages into the area of inter- est(11,12) and modulating their activities so that the ob- struction is cleared and the lymphatics returned to nor- mal, and enhancing local blood flow(13) to assist in controlling and clearing the inflammatory response. Lymph node nets in the head and neck The main lymph node nets in the head and neck are: Oc- cipital (Figure 1); Pre-auricular (Figure 2); Right and Left Submandibular (Figure 3); Submental (Figure 4); Lateral cervical (Figure 5); Deep superior cervical (Fig- ure 6); Deep inferior cervical (Figure 7); Mastoid (Figure 8);andsupraclavicular(Figure9).(14) Themainpalpable lymph node nets in the head and neck are: Occipital, Pre-Auricular, Right and Left Submandibular, Sub- mental, and Cervical (only the superior cervical nodes), as observed in Figure 10. ORIGINAL ARTICLES 68 L. ALMEIDA-LOPES ET AL. Fig 1: The occipital lymph nodes. Fig: 2: The preauricular lymph nodes. Fig 3: The right and left submandibular lymph nodes.
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  ORIGINAL ARTICLES LASER THERAPY-ASSISTEDLYMPHATIC DRAINAGE 69 Fig 4: The submental lymph nodes. Fig 5: The lateral cervical lymph nodes. Fig 6: The deep superior cervical lymph nodes. Fig 7: The deep inferior cervical lymph nodes. Fig 8: The mastoid lymph nodes. Fig 9: The supraclavicular lymph nodes.
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  Main Lymph NodeChains A description will now be given of the main lymph node chains, and their possible roles in dealing with infections of the face likely to be encountered in dental practice through laser therapy-assisted lymph node drainage. Pre-auricular lymph nodes The drainage area of these nodes is limited to the cutane- ous surface, corresponding to the anatomical location of temporomandibular joint (TMJ) and to the point of in- sertion of the masseter muscle into the zygomatic arch. Inflammation of these nodes can occur as a result of an infection of or trauma to the TMJ, or it can represent the presence of an impacted or enclosed mandibular third molar, (retained mandibular third molar syndrome). Iatrogenic pain caused by orthodontic treatment with fixation apparatus, during and after treatment, can be reduced or avoided with the application of laser in the trigeminal passage. Figure 11 illustrates the laser irradi- ation on these lymph nodes. Please note that the visible light laser used in Figures 11 – 14 is to show the laser en- ergy involvement over and around the irradiated nodes. Actual treatment was performed with an 830 nm near infrared GaAlAs diode laser, and appropriate eyewear was worn by both the patients and clinician. Mastoid lymph nodes Formerly called the post-auricular nodes, these nodes are topographically coincident with the occipitomastoid suture, where inflammation of them indicates scalp in- fection. They can be palpated with circular digital movements around the mastoid apophysis and are gen- erally easily felt because of the perfect location of the bone structure. The mastoid lymph capillary nets have nothing to do with the oral or dental structures, nor with their respective sustaining tissues. Submandibular lymph nodes These are formed bilaterally in two symmetrical chains: right and left. They indicate infection of, or neoplasm formation on the surface of the mouth, tongue floor and vestibular face of the lower lip. They are the most fre- quently affected nodes in infections of the tongue, body of the mouth, and the maxillary and mandibular molars. Figure 12 demonstrates laser irradiation on these lymph nodes. ORIGINAL ARTICLES 70 L. ALMEIDA-LOPES ET AL. Fig 10: The main palpable lymph node nets in the head and neck. Fig 11: Laser therapy demonstrated on the preauricular lymph nodes. Note the protective eyewear worn by the patient. In Figures 11 – 14, please refer to the text for the areas drained by the particular nodes being irradiated, and the possible disease or pathologicalentitiesassociatedwiththetherapy. Fig 12: Laser therapy demonstrated on the submandibular lymph nodes.
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  Submental lymph nodes Swellingof these nodes indicates neoplastic alteration or infection on the floor of the mouth, belly of the tongue or mandibular incisors, or sialoadenopathies in the glands of the region already mentioned. Detailed know- ledge of the anatomy is essential for the therapist. These nodes always precede acute inflammatory alterations of the mouth, some of which can be very serious, such as Ludwig’s angina. The submental chains converge to the mediastinal area, and if an acute septic alteration is not detected early enough, in rare cases the appearance of mediastinitis can result. Figure 13 demonstrates laser ir- radiation on these lymph nodes. Cervical lymph nodes The nodal cervical chains are divided, for methodologi- cal purposes, into the superficial cervical and deep cervi- cal nodes. Both can be upper or lower. The deep cervical lymph nodes cannot be easily palpable and therefore are of no semiological concern to the examiner, but the up- per, both anterior and lateral, may be related to scalp in- fection but rarely to mouth and pharynx infection (Figure 14 shows laser irradiation on these lymph nodes). The large volume of the trapezoid muscle does not allow evaluation of the lymph nodes located in the rear portion of the neck, but the chains located in the an- terior portion of the neck, both in the supra- and in- fra-hyoid regions, down to the clavicle, can be evaluated by digital palpation, not only using the finger tips but also by the bilateral palpation method, using the index and middle fingers tips of both hands. Altered lymph nodes of an inflammatory type These are usually identified by an increased volume, slight to extreme tenderness to the touch, mobile and with a slight increase in temperature due to the infec- tion-related inflammatory process. The volume increase felt by palpation, however, does not always indicate a true infection: sometimes it means the presence of a lymph node which has suffered, at some point, a greater demand of its activity because of an acute, but now ter- minated, infection. The lack of any elevated tempera- ture and tenderness allow for a differential diagnosis. These are called residual lymph nodes, and do not re- quire any intervention with laser therapy. Case Report: Treatment of herpes simplex of the lips (herpes labialis) ‘Cold sores’ on or around the lips, herpes labialis, are caused by herpes simplex virus type 1 (HSV-1). This is the most common herpes simplex virus among the gen- eral population and is usually acquired in childhood, so that by adulthood up to 90% of individuals will have an- tibodies to HSV-1. Once the virus is acquired, it spreads to nerve cells in the lips, mouth or face, and remains dor- mant. It may intermittently reactivate and cause symp- toms known as flares. Reactivation can be due to a variety of conditions, such as overexposure to sunlight, minor trauma, fever, stress, acute illness, and medica- tions or conditions that weaken the immune system. Herpes infections are also rather common after laser re- surfacing of the face. The lymph nodes draining the ar- eas affected by the lesions often themselves become swollen and tender, aiding in the diagnosis of herpes simplex-mediated inflammation. Warning symptoms of , a tingling sensation, in- creased sensitivity or burning may appear about 2 days prior to the formation of the lesions. The lesions them- selves can take several forms: s or a rash around the lips, mouth, and gums; small vesicles filled with a clear, yel- lowish fluid; blisters that form then break and ooze, or are on a red, raised and painful area of the skin; or sev- eral smaller blisters that merge to form a single larger ORIGINAL ARTICLES LASER THERAPY-ASSISTED LYMPHATIC DRAINAGE 71 Fig13: Lasertherapysimulatedonthesubmentallymphnodes. Fig14: Lasertherapyillustratedonthecervicallymphnodes.
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  blister. If herpeslabialis lesions remain untreated, they usually subside in 1 – 2 weeks, but in cases where the pa- tient exacerbates the lesions by constantly touching them with the fingers or exploring them with the tongue, or self-excoriation of the crust, they may en- large and last for several weeks. Figure 15a shows a young female patient in the early phase of vesicle formation, particularly evident just beneath the philtrum. Note also the two other less evident sites of infection shown by the arrowheads. La- ser therapy with an infrared diode laser at 830 nm, 70 J/cm2 per point, points treated over the affected submental and sublingual lymph nodes. The patient was treated in two sessions, with two days between ses- sions, and Figure 15c shows the excellent result with the major lesions on the upper lip never having reached the crusting phase, and the lesions marked with arrowheads in Figure 15a never having reached the vesicular stage. This result should be compared with the best case result of a 1-week resolution with topical and/or oral anti- herpetic medication. Discussion The influence on lymphocytes of low incident levels of laser energy was described by as early as 1978(15) and the effect on the lymphatic system has since then been stud- ied by several researchers. (16-21) Low incident levels of laser and light energy have had reported antiviral ef- fects(22) and also on reducing the tissue-damaging reac- tive oxygen species production of immunologically- stressed neutrophils(23) in addition to increasing and ac- celerating their capacity to identify and move to targets (chemotaxis), phagocytosis and internalization of these targets.(24) In the case of herpes simplex lesions, traditionally these have been treated over the actual vesicles them- selves,(25) applying the laser to the actual lesion. Al- though success has been demonstrated with this approach, there are concerns about enhanced activation or even dissemination of viral cells. The authors have been using the lymphatic drainage technique described above for the past 6 years, avoiding the conventional di- rect lesion irradiation technique. The advantage of the lymphatic drainage technique presented here is the avoidance of the activation of the microorganisms that infect the lesion area, in case of highly contaminated le- sions (as it is with the herpes in the vesicle phase), suppu- rative acute apical lesions, or acute cases of pericoronitis or alveolitis. This technique aims at activating the pa- tient’s local immunity, as well as activating the drainage of the region, allowing the patient to go through an ac- celerated inflammatory phase with minor edema, and consequently less pain and discomfort.(26,27) ORIGINAL ARTICLES 72 L. ALMEIDA-LOPES ET AL. Fig 15: Laser Therapy-assisted lymphatic drainage applied in a case of herpes labialis in a young female patient. a: Pre-therapy findings. Vesicular lesions can be seen under the philtrum, but two prevesicular lesions are identified with the arrowheads. b: Treatment of the submental lymph nodes with a GaAlAs diode laser at 830 nm. The sublingual nodes were also treated. Note the sterile plastic wrap over the laser handpiece. c: Af- ter 2 treatment session, two days between sessions, the result is excellent with almost total resolution of the lesions. The vesicular lesions have not reached the crusting stage, and the lesions marked with arrow- heads in (a:) have not reached the vesicular stage.
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  Conclusions This laser therapy-assistedlymphatic drainage tech- nique is effective for the clinical treatment of inflamma- tion in the facial and mouth areas, through activation of the local drainage, reduction of oedema and increased the blood flow rate and volume in the irradiated, com- bined with restoration then acceleration of lymphatic drainage. The ideal indication would be in those highly contaminated acute processes, where the direct applica- tion of laser energy could activate the microorganisms of the region, exacerbating the infectious process, instead of reducing it. The technique is easy to apply, painless, well tolerated by all patients, even those with dento- phobia, and has proved extremely safe and very effica- cious. Editorial Note: The Managing Editor would like to acknowledge the first class hand-drawn illustrations from Professor Atillo Lopes, of the Department of Oral Pathology, College of Dentistry of the University Camilo Castelo Branco in São Paulo. Prof Lopes is an excellent medical illustrator, as can be seen from the illustrations of the main lymph node networks in this article. In the interests of cost, however, these have been converted to half tone images from the original colour illustrations, and have been relabelled in English from the original Brazilian. Any readers interested in seeing the original colour illustra- tions in all their glory can do so on the internet at www.lasertherapy-journal.com/atillo-illus.html. At the same time, why not have a look at the journal website (follow the link from the previous web page). References 1: Labajos M, Fernández-Perez M D, Ruiz A et al. (1986): Ef- fects of the IR radiation of the GaAs diode laser on intestinal absorption in vitro and in vivo studies. Laser, 2: 21-25. 2: Lievens P: The influence of laser-irradiation on the motricity of the lymphatical system and on the wound healing process. In: International Congress on Laser in Medicine and Surgery. 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  25: Schindl A,Neuman R (1999): Low-intensity laser therapy is an effective treatment for recurrent herpes simplex infec- tion. Results from a randomized double-blind placebo con- trolled study. J Investigative Dermatolog, 113: 221.223. 26: Almeida-Lopes L: Present Situation of the Dental Word Re- garding to the use of LLT. In: Proceedings of the Fourth World Congress – World Association for Laser Therapy, Tsukuba, Japan, 2002, p. 43-48. Monduzzi Editore, Bolo- gna, Italy. 27: Almeida-Lopes L, Figueiredo ACR, and Lopes A (2002): O uso do laser terapêutico no tratamento da inflamação nas clínica odontológica, através da drenagem linfática. Revista da APCD, 56: supl., pág. 27. ORIGINAL ARTICLES