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Infrared Diode Laser Therapy-Induced Lymphatic Drainage for Inflammation in the Head and Neck

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Infrared Diode Laser Therapy-Induced Lymphatic Drainage for Inflammation in the Head and Neck 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 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 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 © 2005 JMLL Ltd. Laser Therapy 14.2: 67-74 67 ORIGINAL ARTICLES 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. 68 L. ALMEIDA-LOPES ET AL. ORIGINAL ARTICLES Fig 4: The submental lymph nodes. Fig 7: The deep inferior cervical lymph nodes. 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. LASER THERAPY-ASSISTED LYMPHATIC DRAINAGE 69 ORIGINAL ARTICLES 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, tongue floor and The drainage area of these nodes is limited to the cutane- vestibular face of the lower lip. 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.
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