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Two different approaches of Low-Level Laser Therapy to treat patients with hyposaliva. A pilot study.

By Michael Nylander, DDS, MSci

A Master Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of Master of Science in Lasers in Dentistry at the Rheinisch-Westfälische Technische Hochschule Aachen. September 2012

Advisor: Prof. DDS, PhD. Marcia Martins Marques

 

Abstract

Introduction: The volume of saliva in resting and chewing stimulated conditions are higher than 0.25 and 1.0 ml/min, respectively. Patients with lower secretion of saliva can experience problems related to oral function as well as quality of life regardless the actual diagnosis of the basal pathological condition of such patients if xerostomia, hyposalivation, or altered saliva composition. Low level laser therapy (LLLT) is able to increase salivary flow then, has being pointed as beneficial as an auxiliary therapy for hypofunction of salivary glands. However, the most appropriate parameters of LLLT as well as application approaches are still to be defined.

Objective: The aim of this study was to test different approaches of LLLT (e.g. two in-office LLLT versus at-home LLLT) in order to increase the salivary flow and diminish the discomfort of patients with hyposaliva.

Materials and Methods: Nine patients with hyposaliva received in-office LLLT twice a week for three weeks. Then, they were randomly divided into 3 groups, as follows: G1 (control group)-No further LLLT; G2-In-office LLLT once a month; G3-At-home LLLT: the patients were trained to treat himself with a laser equipment (Treatlite ®) three times a week during 6 months. The LLLT was applied in the salivary glands (both sides). For the in-office LLLT the Elexxion diode laser was used with the following parameters: 810 nm, 60mW, 1800 Hz, spot size of 12.52 mm², in contact mode, 7.2 J (parotis gland), 4.8 J (submandibularis gland) and 3 J (lingualis gland). The total energy was 30 J. For at-home LLLT the Treatlite ® was used with the following parameters: 808 nm, 75 mW, CW, probe diameter 50.24 mm², in contact mode 6.75 J (parotid gland) 4.5 J (mandibularis gland) and 3 J (lingualis glands). The total energy was 28.5 J. The volume, pH and amount of bacteria of resting and chewing stimulated saliva from patients of all groups were obtained in the first appointment, then in 3 weeks and once a month until the end of the study (6 months). For discomfort assessment the VAS scale was used in the first and last appointments.

Results: Patients of G1 returned to the office until 15 weeks, and the remaining patients (G2 and G3) were followed until 23 weeks. Except by 2 patients that quit treatment due to illness and 1 diagnosed as Sjögren’s syndrome patient, the volume of resting saliva showed a trend to increase in 3 weeks, then, this trend of increase was maintained in patients of all groups (5 out 6). The chewing stimulated saliva also presented a trend to increase in most patients during the first 3 weeks and this trend was maintained until the end of the experiment. There were no changes in bacterial content, neither in pH of the saliva throughout the experimental time in all patients.

Conclusion: LLLT performed in–office or at –home are able to improve, up to 6 months, the secretion of saliva. These treatments for patients with hyposaliva diminish their discomfort, ultimately leading to a upgrading of their quality of life.

 

Introduction

Saliva plays a key role in maintaining oral health and function. Xerostomia is the subjective sensation of oral dryness while salivary gland hypofunction is the objective observation of reduced salivary flow.[1] The term dry mouth has been used to describe both conditions.[1] The aetiology of xerostomia and salivary gland hypofunction includes age, diseases, medications, iatrogenic, and idiopathic.[2]. Xerostomia may be indicative of other health problems and affects oral health and quality of life [3]. Salivary gland hypofunction can have a negative impact on oral health, such as caries, fungal infection, and difficulty in dental treatment. Other problems associated with salivary gland hypofunction include burning mouth syndrome, taste changes, aspiration, altered sensation, and difficulty in chewing, swallowing, and speech [2].

Dry mouth has become a major complaint in elderly dental patients. The goals of the present article were to review existing research on the aetiology, diagnosis, and epidemiology of dry mouth in the vulnerable elderly and identify knowledge gaps for future investigation. The vulnerable elderly population constitutes a unique group of patients that demand special attention to their salivary functions to maintain quality of life.

Low level laser therapy (LLLT) is able to increase salivary flow then, has being pointed as beneficial as an auxiliary therapy for hypofunction of salivary glands. However, the most appropriate parameters of LLLT as well as application approaches are still to be defined. Thus, the aim of this study was to test different approaches of LLLT (e.g. two in-office LLLT versus at-home LLLT) in order to increase the salivary flow and diminish the discomfort of patients with hyposaliva.

 

Review of the literature

For the purposes of this article, vulnerable elderly are persons aged >65 years that have any or all of the following: limited mobility, limited resources, or complex health status. They often suffer from chronic diseases and use multiple medications, both of which can impair the function of salivary glands. Therefore, the vulnerable elderly population constitutes a unique group of patients that demand special attention to their salivary functions to maintain quality of life. There are many studies focusing on xerostomia and salivary gland hypofunction in elders; however, no reviews are available targeting the vulnerable elderly specifically. With the increase in life expectancy of the global population, such a review will help identify the impact of xerostomia and salivary gland hypofunction in vulnerable elderly and facilitate their health care needs. Finally, the challenges of salivary research in vulnerable elderly and future research directions are discussed. Management and treatment of xerostomia and salivary gland hypofunction in vulnerable elderly are not included in this review.

Today, the number of elderly patients has been increasing worldwide, many of them suffer from dry mouth, but it also occurs in younger patients. Many patients suffering from hyposaliva have difficulty getting to the clinic for treatment to the extent needed due to the nature of that they are sick and lacking energy. The purpose of this study is to compare two treatments, a method in which patients treated in the clinic and a method in which patients start treatment at the clinic and then treat themselves at home.

Salivary glands

Humans have three major salivary glands, and several minor salivary glands.

They major salivary glands are paired and are situated in the cheek above the maxillary molars and the floor of the mouth Fig1: Salivary glands consist of secretion vesicles in which saliva is formed and transferred into the oral cavity through the various aisles, where some modification of saliva occurs. Saliva contains mainly water and various salts, enzymes and proteins whose function is to promote the digestion of food. Saliva also prevents the lining of the mouth from drying out and protects oral tissues against noxious compounds [1] .The lack of saliva increases the risk of dental caries and periodontal disease, mouth ulcers and fungal infections. [2] Many also experience pain and burning sensations [4]. The most common reason for lack of saliva is medication, which creates a dry mouth as a side effect. [3] [4] [5]

Examples of these are: drug treatment (e.g. anticholinergics, antidepressants, antipsychotics, anticonvulsants, centrally acting analgesics, many seize drugs); diseases (e.g. Sjögren’s syndrome, rheumatic disorders, depression, labile diabetes mellitus[5]) , radiotherapy of the head and neck [6], mouth breathing dehydration (saliva secretion decreases markedly in a dehydrated patient) during stimulation and inactivity (such as severe illness that often gives dry mouth among other things because of low activity). The ability of the patient may be included in the study is that we can diagnose hyposaliva. Previous studies with rats have demonstrated that LLLT treatment stimulates diseased salivary glands to normal function [14][15] [16] [17], and some publications that show that one can stimulate salivary glands with low level laser therapy in humans [7] [8] [9] [10] [11]. The purpose of this study is to find an adequate treatment dose and appropriate treatment interval with LLLT, and investigate whether patients can treat themselves with a laser at home with acceptable results.

Material and Methods

Sampling

To the patents who visited the clinic between November 2011 and April 2012 and experienced problems with dry mouth were offered a survey to ascertain hyposaliva. To the patients who could be diagnosed with hyposaliva were offered treatment and these patients were included in the study. Nine patients with hyposaliva participated in the study (6 women and 3 men), mean age 71 years (63-84 year).

All the procedures were explained to the patients and a consent form was signed. We found several other potential patients, but they declined due to illness or lack of energy. The volume, pH and amount of bacteria of resting and chewing stimulated saliva from patients of all groups were obtained in the first appointment, then in 3 weeks and once a month until the end of the study (6 months). For discomfort assessment the VAS scale was used in the first and last appointments.

Saliva secretion assessment

Resting saliva: saliva was collected was between 08:00 and 11:00 am. Patients should not eat, drink or smoke an hour before collection. Additionally, the patient should rest about 15 minutes before saliva collection. The patient sat with upper body leaning forward comfortably relaxed with forearms placed on the thighs. Saliva was allowed to flow passively, drooling over the lower lip into the cup held against the lower lip. The lower jaw should be idle and the chin loosed.  After 15 minutes the patient spat the remaining saliva in the mouth actively into the cup. The calculation of resting salivary secretion (ml / min) was obtained by weighing the cup before the collection of saliva and 15 minutes after. The weight of cup of resting saliva minus the weight of the empty cup divided by 15 gave the resting saliva secretion rate in ml / min.

Chewing stimulated saliva: The patient sat relaxed and chewing a paraffin chewing gum for 5 minutes, spitting actively all the time into a cup. The calculation of chewing stimulated saliva (ml / min) was obtained by weighing the cup before the collection of saliva and after 5 min. The weight of the cup chewing stimulated saliva minus the weight of the empty cup divided by 5 gave the chewing stimulated saliva secretion rate in ml / min.

Bacterial sampling

From the collected saliva samples for bacterial analysis, Candida test and pH measurements were obtained. These samples were obtained before treatment, after 3 weeks and then monthly during the study. For microbiological analysis the Dentocult SM Strip mutans. Dentocult LB. Dentocult CA. Dentobuff from Orion Diagnostica was used [12]. After collection Candida and bacteria samples were stored in cultivation cabinet (35 °C) for two days before analyses. A medical history was taken, to assess illnesses, medications and smoking habits.

Discomfort level assessment

For assessing whether the patient experienced dry mouth (xerostomia) a 10 cm visual analogue scale (VAS) was used. In this scale 1 meant no problems whereas up to 10 described greater suffering (Fig 9).

Experiments

Nine patients with hyposaliva received in-office LLLT twice a week for three weeks. Then, they were randomly divided into 3 groups, as follows:

G1 (control group)-No further LLLT; G2-In-office LLLT once a month;

G3-At-home LLLT: the patients were trained to treat himself with a laser equipment (Treatlite ®) three times a week during 6 months.

Low level laser therapy (LLLT)

The LLLT was applied in the salivary glands (both sides).

For the in-office LLLT the Elexxion diode laser was used with the following parameters: 810 nm, 60 mW, 1800 Hz, spot size of 12.52 mm², in contact mode, 7.2 J (parotid gland; Fig. 2), 4.8 J (submandibular gland; Fig. 3) and 3 J (lingual gland; Fig.4). The total energy was 30 J.

For at-home LLLT the Treatlite ® (Fig.5) was used with the following parameters: 808 nm, 75 mW, CW, probe diameter 50.24 mm2, in contact mode 6.75 J (parotid gland; Fig.6) 4.5 J (submandibular gland; Fig. 7) and 3 J (lingual gland; Fig.8). The total energy was 28.5 J.

The output power of the diode laser was checked with a power meter before treatment started, and after 6 months. No deterioration of the output power could be measured. Treatlite is available with an intraoral probe, but at the time of performing this study, that probe was not available.

Figure 2: In-office in the parotid gland

Figure 3: In-office LLLT in submandibular gland.

Figure 4: In-office LLLT in lingual gland

Figure 5: Treatlite. Size comparison with a 33cl bottle of water

 

Figure 6: At-home LLLT in parotid gland

Figure 7: At-home LLLT in submandibular gland

Figure 8: At-home LLLT in lingual gland

Results

Resting saliva:

Figure 9 illustrates the results on the resting saliva secretion rate (ml/min) of all patients during whole experimental time. After the initial treatment phase in three weeks including nine patients in the study, it was possible to observe an increase in resting saliva. One patient (Pat 7) did not change the resting saliva secretion rate. This patient has been diagnosed with Sjögren’s syndrome for 20 years. Patients 3 and 5 quit the study on 3 weeks due to illnesses.

After 23 weeks, we note that they patients who received supportive treatment with LLLT remain at its highest value, or increased saliva volume ml /min. The exception patient No. 6 with Sjögren’s syndrome, she stopped smoking during the study and had changed medication for pain, from paracetamol to NSAIDs

Figure 9: Graphic representation of the resting saliva secretion rate (ml/min) in function of time (weeks) of patients of all groups. G1: Pat 1, 2 and 3; G2: Pat 4, 5 and 6; G3: Pat 7, 8 and 9.

Chewing stimulated saliva:

Figure 10 illustrates the results on the chewing stimulated saliva secretion rate (ml/min) of all patients during whole experimental time. After the initial treatment phase in three weeks including nine patients in the study, no changes in the saliva secretion was noticed. After that, there was a trend in increasing the chewing stimulated saliva, especially in the patients that received continuing LLLT (G2 and G3). After 7 weeks, only 1 patient had decreased his saliva quantity. Patient No. 3 and 5 have interrupted the study due to disease. After 23 weeks, we can see that the chewing stimulated saliva change followed the same trend as resting saliva.

Figure 10: Graphic representation of the chewing stimulated saliva secretion rate (ml/min) in function of time (weeks) of patients of all groups. G1: Pat 1, 2 and 3; G2: Pat 4, 5 and 6; G3: Pat 7, 8 and 9.

Bacterial analysis

All patients had moderate to high values of Streptococcus mutans and lactobacillus and no values were changed during the study. Candida was found in five of nine patients and the amount of Candida in these patients was unchanged during the study. The saliva buffer capacity was low in all patients and remained unchanged during whole study.

Discomfort assessment (VAS)

All patients experienced less dry mouth, some felt it tingle when they received laser treatment. Figure 11 shows the results of the discomfort level assessment (VAS). Except by patients 3 and 5 that quit the treatment, all other patients showed decrease in the VAS values.

Discussion

Dry mouth has become a major complaint in elderly dental patients. The LLLT applied in the major salivary glands is able to stimulate the secretion of saliva. However, LLLT is more effective when applied in a repetitive basis, and these elderly patients not always can return to the dental office to receive this treatment. Thus, this study analysed the effect of LLLT in an at-home LLLT approach in comparison to two in-office LLLT approaches. The preliminary results showed that the LLLT improved the secretion of saliva (resting and chewing stimulated saliva) and that the effect was independently of the approach used if in-office or at- home. The only treatment that was less effective during the experimental time was the one where after 3 weeks no further treatment was applied.

The results obtained in the 3 weeks is similar to other studies. Although in these studies different settings and other wavelengths were used, they were within the same therapeutic window of this study. [7] [8] [9] [10] [11]. We can see indications that continued support treatment, either with self-treatment three times a week at home, or treatment at a clinic once a month, leading to a continued increase in the amount of saliva, even after 23 weeks.

No side effects were reported. Almost all patients experienced an improvement of dry mouth during and after treatment with LLLT. We could not detect any reduction in the number of bacteria or fungi in the study. Neither did we find an improved buffer capacity of saliva. The number of patients included in the study are too few to establish the results, but must be seen as an indication that support treatment with LLLT adds value to patients with increased salivary secretion. We had an increase in saliva of Sjögren’s syndrome patients, but they responded less to treatment than any of those others in the study. Here we suggest to try other treatment intervals to improve the results. The study will continue for another 2 years where new patients are brought into the study and those who are already in the study will be followed up every 6 months.

The mechanism underlying the laser light stimulation of the salivary glands was not fully investigated. However, previous studies have shown that the singlet oxygen produced when the tissue is irradiated with laser. Singlet oxygen is a free radical which affects the formation of ATP. ATP is a nucleotide that plays a central role in the cell’s energy management. It has also been shown that the laser light affect the oxidative processes which in turn leads to a wide variety of secondary effects: increased cell metabolism, most action potential of the neurons, local impact of the immune system, increased vascularity, an increased amount of leukocytes. etc. [13].

This study is until now only preliminary and the number of patients is too small for allow statistical comparisons; however, they point out to a very important finding. The elderly population can perform the LLLT at home with similar results than LLLT performed in-office. This is a breakthrough in the caring of such population that has difficulties in locomotion, which hinder them to be treated in clinics or hospitals. Thus, although preliminary, this study showed a finding of social importance for the elderly patients with hyposaliva that has a great potential for improving the quality of life of such patients. The increase in saliva secretion has effects in several other health parameters.

The patients of this study are still followed and new patients will be added in order to find solid results supporting this new LLLT approach. New studies with other LLLT parameters must be done always looking for upgrading the quality of life of the elderly population.

Conclusion

Based in the limitations of this study it was concluded that the at-home LLLT is easy to implement and cost effective. It is possible to assign a trained dental hygienist or dental assistant. The treatment has a high patient value and no side effects. Patients who treated themselves with home laser found that it was easy to administer treatment, and were pleased with the results and thought it was affordable.

LLLT treatment of hyposaliva leads to an increase in saliva and the study suggests that a supportive treatment with LLLT provides a continued increase in saliva for up to 6 months. Supportive treatment can be performed equally well in the clinic as by patients treating themselves at home

ACKNOWLEDGMENTS

The author wishes to express sincere appreciation to Jan Tunér, DDS for his assistance in the preparation of this manuscript.

References

[1] Antimicrobial function of human saliva - how important is it for oral health? 1998, Vol. 56, No. 5, Pages 250-256 (doi:10.1080/000163598428400) Jorma Tenovuo.

[2] Xerostomia: diagnosis and management, Department of Stomatology, University of California at San Francisco, USA. Oncology (Williston Park N.Y) [996, 10(3 Suppl):7-11.

[4] Burning mouth syndrome Grushka M, Epstein JB,Gorsky M William Osler Health Center, Toronto, Ontario, Canada. mgrushka@yahoo.com American Family Physician 2002, 65(4):615-20].

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[10] Simões A, Platero MD, Campos L, Aranha AC, Eduardo Cde P, Nicolau J. Laser as  a therapy for dry mouth symptoms in a patient with Sjögren’s syndrome: a case report. Spec Care Dentist. 2009 May-June;29(3):134-7. PubMed PMID: 19938253.

[11] Vidović Juras D, Lukac J, Cekić-Arambasin A, Vidović A, Canjuga I, Sikora M, Carek A, Ledinsky M. Effects of low-level laser treatment on mouth dryness. Coll Antropol. 2010 Sep;34(3):1039-43. PubMed PMID: 20977100.

[12] 2008 Orion Diagnostica Oy, P.O.Box 83, FI-02101 Espoo, Finland.

[13] Hode L. Laser That Heals. Swedish Laser-Medical Society, Stockholm, Sweden.

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[15 Simões A, Ganzerla E, Yamaguti PM, de Paula Eduardo C, Nicolau J. Effect of diode laser on enzymatic activity of parotid glands of diabetic rats. Lasers Med  Sci. 2009 Jul;24(4):591-6. doi: 10.1007/s10103-008-0619-2. Epub 2008 Nov 4. PubMed PMID: 18982402.

[16] Effect of defocused infrared diode laser on salivary flow rate and some salivary parameters of rats Alyne Simões & José Nicolau & Douglas Nesadal de Souza & Leila Soares Ferreira & Carlos de Paula Eduardo & Christian Apel & Norbert Gutknecht Received: 5 December 2006 Accepted: 13 June 2007 / Published online: 12 July 2007.

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