ORIGINAL ARTICLES

INFRARED DIODE LASER THERAPY-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 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 the affected lymphatics offers another approach. Although lymphatic drainage is frequently used in the clinical 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 lymphatic system The therapeutic laser has been used since the 1980’s in The lymphatic system consists of well-differentiated tis- cases of inflammation, acting as a mediator in these pro- sue groups which are ultrastructurally distinct and cesses, activating the lymphatic flow in the irradiated re- widely spread, ‘Lymph’ comes from the Greek via the gion(1-5) in addition to stimulating the local autoim- Latin ‘lympha’ and means ‘clear water’, which is what mune system of the patient.(6-8) Because of these proper- the Ancient anatomists found during dissection in what ties, laser therapy has been successfully indicated for they believed were part of the venous system. The com- lymphatic drainage in cases of inflammation in both plex system of lymphatic vessels has several functions. It acute (exudative inflammation) and chronic (prolifer- drains excess exvasated extracellular fluids back into the ative inflammation) cases. The present study reviews the blood circulation, is an important component of the localization of the main palpable lymph nodes in the scavenging and homeostatic system, and a very impor- head and neck, the function of each of the lymph node tant component of the autoimmune system as part the networks, and presents a technique for the treatment of first line of defence of the body against viral or bacterial cases of inflammation through the lymphatic drainage attack. The lymphatic system not only acts as a filtration stimulated by the application of laser therapy. system to trap and then destroy cellular debris from the vascular system and connective tissue, it is also the main Addressee for Correspondence: repository and ‘superhighway’ for the various types of Luciana Almeida-Lopes DDS PhD. lymphocytes to enable them to be recruited to any area Rua Tibães, 22-Jd. São Bento, of the body where they are needed. CEP 02525.030 Sao Pãulo, Brazil Manuscript received: December 2004 e-mail: [email protected] Accepted for publication: February 2005

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The lymph vessels start 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- Fig 1: The occipital lymph nodes. 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 Fig: 2: The preauricular lymph nodes. 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); and supraclavicular (Figure 9).(14) The main palpable 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), Fig 3: The right and left submandibular lymph nodes. as observed in Figure 10.

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Fig 4: The submental lymph nodes. Fig 7: The deep inferior .

Fig 5: The lateral cervical lymph nodes. Fig 8: The mastoid lymph nodes.

Fig 6: The deep superior cervical lymph nodes. Fig 9: The supraclavicular lymph nodes.

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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 pathological entities associated with the therapy. Fig 10: The main palpable lymph node nets in the head and neck. erally easily felt because of the perfect location of the bone structure. The mastoid lymph capillary nets have Main Lymph Node Chains nothing to do with the oral or dental structures, nor with A description will now be given of the main lymph node their respective sustaining tissues. chains, and their possible roles in dealing with infections Submandibular lymph nodes of the face likely to be encountered in dental practice These are formed bilaterally in two symmetrical chains: through laser therapy-assisted lymph node drainage. right and left. They indicate infection of, or neoplasm Pre-auricular lymph nodes formation on the surface of the mouth, floor and The drainage area of these nodes is limited to the cutane- vestibular face of the lower . They are the most fre- ous surface, corresponding to the anatomical location of quently affected nodes in infections of the tongue, body temporomandibular joint (TMJ) and to the point of in- of the mouth, and the maxillary and mandibular molars. sertion of the masseter muscle into the zygomatic arch. Figure 12 demonstrates laser irradiation on these lymph Inflammation of these nodes can occur as a result of an nodes. 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 Fig 12: Laser therapy demonstrated on the submandibular lymph nodes. suture, where inflammation of them indicates scalp in- fection. They can be palpated with circular digital movements around the mastoid apophysis and are gen-

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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 Fig 13: Laser therapy simulated on the submental lymph nodes. 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 Submental lymph nodes felt by palpation, however, does not always indicate a Swelling of these nodes indicates neoplastic alteration or true infection: sometimes it means the presence of a infection on the floor of the mouth, belly of the tongue lymph node which has suffered, at some point, a greater or mandibular incisors, or sialoadenopathies in the demand of its activity because of an acute, but now ter- glands of the region already mentioned. Detailed know- minated, infection. The lack of any elevated tempera- ledge of the anatomy is essential for the therapist. These ture and tenderness allow for a differential diagnosis. nodes always precede acute inflammatory alterations of These are called residual lymph nodes, and do not re- the mouth, some of which can be very serious, such as quire any intervention with laser therapy. Ludwig’s angina. The submental chains converge to the mediastinal area, and if an acute septic alteration is not Case Report: Treatment of herpes simplex of the detected early enough, in rare cases the appearance of (herpes labialis) mediastinitis can result. Figure 13 demonstrates laser ir- radiation on these lymph nodes. ‘Cold sores’ on or around the lips, herpes labialis, are Cervical lymph nodes caused by herpes simplex virus type 1 (HSV-1). This is The nodal cervical chains are divided, for methodologi- the most common herpes simplex virus among the gen- cal purposes, into the superficial cervical and deep cervi- eral population and is usually acquired in childhood, so cal nodes. Both can be upper or lower. The deep cervical 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- Fig 14: Laser therapy illustrated on the cervical lymph nodes. 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

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blister. If herpes labialis lesions remain untreated, they usually subside in1–2weeks, 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- Fig 15: Laser Therapy-assisted lymphatic drainage applied in rect lesion irradiation technique. The advantage of the a case of herpes labialis in a young female patient. a: Pre-therapy findings. Vesicular lesions can be seen lymphatic drainage technique presented here is the under the philtrum, but two prevesicular lesions are avoidance of the activation of the microorganisms that identified with the arrowheads. b: Treatment of the infect the lesion area, in case of highly contaminated le- submental lymph nodes with a GaAlAs diode laser at 830 nm. The sublingual nodes were also treated. Note sions (as it is with the herpes in the vesicle phase), suppu- the sterile plastic wrap over the laser handpiece. c: Af- rative acute apical lesions, or acute cases of pericoronitis ter 2 treatment session, two days between sessions, the or alveolitis. This technique aims at activating the pa- result is excellent with almost total resolution of the lesions. The vesicular lesions have not reached the tient’s local immunity, as well as activating the drainage crusting stage, and the lesions marked with arrow- of the region, allowing the patient to go through an ac- heads in (a:) have not reached the vesicular stage. celerated inflammatory phase with minor edema, and consequently less pain and discomfort.(26,27)

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Conclusions acyclovir administered orally. In: The International Society for Optical Engineering. Proceedings SPIE, 2650: 43-50. This laser therapy-assisted lymphatic drainage tech- 7: Tunér J, and Hode L (1996): Laser Therapy in Dentistry nique is effective for the clinical treatment of inflamma- and Medicine, Prima Books AB, Sweden. tion in the facial and mouth areas, through activation of 8: Yu W, Chi LH, Naim JO, and Lanzafame RJ (1997): Im- the local drainage, reduction of oedema and increased provement of host response to sepsis by photobiomodulation. the blood flow rate and volume in the irradiated, com- Lasers Surg Med, 21: 262-268. 9: Verlag GT: Terminologia Anatômica Internacional bined with restoration then acceleration of lymphatic (Sociedade Brasileira de Anatomia) (FCAT). Ed. Manole, drainage. The ideal indication would be in those highly Brasil, 2001. contaminated acute processes, where the direct applica- 10: Michalany J: Anatomia Patológica Geral na Prática tion of laser energy could activate the microorganisms of Médico-Cirúrgica. Livraria Editora Artes Médicas Ltda, the region, exacerbating the infectious process, instead Brasil, 1995. of reducing it. The technique is easy to apply, painless, 11: Young S, Bolton P, Dyson M, Harvey W, and well tolerated by all patients, even those with dento- Diamantopoulos C (1989): Macrophage responsiveness to light therapy. Lasers Surg Med, 9: 497-505. phobia, and has proved extremely safe and very effica- 12: Yamaya M, Shiroto C, Kobayashi H, Naganuma S, cious. Sakamoto J, Suzuki K-J, Kanaji S, Sugawara K, and Kumae T (1993): Mechanistic approach to GaAlAs diode laser ef- Editorial Note: fects on production of reactive oxygen species from human neutrophils as a model for therapeutic modality at a cellular The Managing Editor would like to acknowledge the level. Laser Therapy, 5: 111-116. first class hand-drawn illustrations from Professor Atillo 13: Kubota J (2002): Effects of diode laser therapy on blood Lopes, of the Department of Oral Pathology, College of flow in axial pattern flaps in the rat model. Lasers Med Sci, Dentistry of the University Camilo Castelo Branco in 17: 146-153. 14: Spalteholz W: Atlas de Anatomia Humana, Vol. III, Ed. São Paulo. Prof Lopes is an excellent medical illustrator, Labor S.A, Barcelona, 1984. as can be seen from the illustrations of the main lymph 15: Mester E, Nagylucskay S, Waidelich W, Tisza S, Greguss P, node networks in this article. In the interests of cost, Haina D and Mester A (1978): Effects of direct laser radia- however, these have been converted to half tone images tion on human lymphocytes. Arch Dermatol Res, 263: from the original colour illustrations, and have been 241-245. (Article originally in German, translated into English relabelled in English from the original Brazilian. Any by EM). readers interested in seeing the original colour illustra- 16: Meyers A, Joyce J, and Cohen J (1987): Effects of low-watt Helium Neon laser radiation on human lymphocyte cul- tions in all their glory can do so on the internet at tures. Lasers in Surgery and Medicine, 6: 540 www.lasertherapy-journal.com/atillo-illus.html. At the 17: Inoue K, Nishioka J, and Fukuda S (1989): Altered lym- same time, why not have a look at the journal website phocyte proliferation by low dosage laser irradiation. Clin (follow the link from the previous web page). Exp Rheumatol, 7: 521-523. 18: Manteifel V, Andreichuk T, Karu T et al. 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25: Schindl A, Neuman R (1999): Low-intensity laser therapy is Tsukuba, Japan, 2002, p. 43-48. Monduzzi Editore, Bolo- an effective treatment for recurrent herpes simplex infec- gna, Italy. tion. Results from a randomized double-blind placebo con- trolled study. J Investigative Dermatolog, 113: 221.223. 27: Almeida-Lopes L, Figueiredo ACR, and Lopes A (2002): O 26: Almeida-Lopes L: Present Situation of the Dental Word Re- uso do laser terapêutico no tratamento da inflamação nas garding to the use of LLT. In: Proceedings of the Fourth clínica odontológica, através da drenagem linfática. Revista World Congress – World Association for Laser Therapy, da APCD, 56: supl., pág. 27.