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Yakimenko Dmytro Olegovich, Odessa national medical university, Odessa, Ukraine E-mail: [email protected]
CORRECTIVE EFFECT OF LASER THERAPY ON THE STATE OF LOCAL ORAL CAVITY RESISTANCE IN PATIENTS WITH SJOGREN'S DISEASE
Abstract: the effect of laser therapy on the state of oral cavity resistance in the complex treatment of Sjogren's disease was investigated. It has been established that laser irradiation of parotid salivary gland reduces manifestations of xerostomia, increases salivation, normalizes the cell composition of the liquid of oral cavity, reduces the Greene-Vermillion index.
Keywords: Sjogren's disease, oral cavity resistance, laser therapy.
Background. Saliva is an important biological substance which is part of oral fluid. About 1,5 liters of saliva are produced in one day in healthy body, the saliva moisturizes the mucous membranes of the mouth and esophagus, digested food; saliva with the cellular population of the oral cavity contributes to controlling the microbial population of the mouth due to presence of antibacterial factors, promotes mineralization and strengthening of teeth [1; 2].
Reduction of saliva production occurs in healthy people with emotional overload, in diseases - diabetes mellitus, hyperthyroidism, taking some medications (antidepressants, diuretics, etc.). The prevalence of xerostomia correlates with age - among people under the age of 50 years old it is observed in 6% of population, and in people of 65 years old - in 15% [2; 3]. However, the most expressed xerostomia is observed rheumatic pathology - rheumatoid arthritis [4-7], systemic scleroderma, and especially -in Sjogren's disease (SjD) [9-12].
Sjogen's disease is a systemic disease of glands of external secretion with predominant affection of salivary, lacrimal glands and also glands of gastrointestinal tract. Subjective signs of this disease are damages of eyes (dry keratoconjunctivitis) and oral cavity (from decrease of saliva production to it's complete absence) [9-12]. There may be signs of
decreased functions of other exocrine glands (sweat glands, glands of gastrointestinal tract), which lead to development of dry skin, atrophy of gastric and intestinal mucous membranes [12-15].
Systemic manifestations of this disease include lymphadenopathies, arthralgia or arthritis, Raynaud's syndrome, affection of gastrointestinal tract, lungs, heart, kidneys, cytopenia, phenomena associated with hyperproduction of antibodies (hyperviscosity syndrome, the appearance of cryoglobulins, rheumatoid factor, antinuclear antibodies, antibodies Ro/SS-A and La/SS-B) [9; 15; 16].
The activity in the pathological process of structures related to immune response system changes the cellular composition of the oral cavity fluid, which reduces the protective capabilities of oral mucosa and leads to rearrangement of the microbial landscape of the oral cavity and promotes the development of autoimmune inflammation in the salivary glands and oral cavity [9; 10].
Therefore, the most important task of treatment of such patients is to reduce the intensity of autoimmune inflammatory process in the salivary glands. Systemic glucocorticoids are used for the treatment of SjD, and in the presence ofvasculitis the cytostatics should be used. Also locally artificial tears, mouth-wash and drinking water while eating can be applied
[9; 13; 17; 18]. However, the desired effectiveness of therapeutic complexes is not always achieved. It should also be noted that the inclusion of physical factors in the treatment of SjD is not fully worked out, particularly the ability to influence by these factors on the resistance of mucous membrane of oral cavity for correction of autoimmune inflammation. The purpose of the study is to determine the effect of laser irradiation on the cellular composition of oral cavity as important component of local resistance.
Materials and methods. 42 patients with Sjogren's disease were examined, all of them are women, the average age of patients was 53.5 ± 1.1 years old. The duration of disease was from 2 to 6 years (average duration 3.7 ± 0.2 years).
A clinical, laboratory and instrumental investigation was conducted, which included analysis of complaints, anamnesis. The research was carried out by rheumatologist, stomatologist and ophthalmologist. In the objective examination, particular attention was paid to the condition of mucous membrane of eyes and oral cavity. We conducted the Schirmer's test.
For studying of cellular composition of the oral liquid in patients, the fluid was collected from sublingual fossa during 10 minutes with the use of special capsule. The resulting liquid was centrifuged at 10,000 rpm for 4 minutes. From the precipitate which formed in the test tube, smears were prepared, which stained by hematoxylin-eosin after fixation in vapors of alcohol-ether during 2 hours. The obtained specimens were studied using a light microscope. In 10 fields the number of lymphocytes, neutrophils, epithelial cells, "bare nuclei" (a sign of activity of the autoimmune reaction) were counted, in total at least 150 cells. Then we counted their relative number in the cell population of oral cavity.
Laboratory investigation included general blood and urine tests, determination of total protein and fractions, glucose, bilirubin, creatinine, rheumatoid factor and interleukin-1 in blood. The antinuclear antibodies, anti-Ro/SS-A and anti-La/SS-B antibodies were detected. The contents of lysozyme and secre-
tory IgA (SIgA) in saliva before and after treatment were studied. Electrocardiogram and X-ray of chest organs were performed.
The diagnosis was verified according to the criteria of the Institute of Rheumatology (2001) [9].
All patients were treated with methylpredniso-lone in adequate doses, in the main group with complex therapy we added the infrared laser on the area of parotid glands. We applied the apparatus of laser therapy "Uzor", on the projection of parotid glands by local contact, radiation power 7 W, frequency 300 Hz, exposure 3-4 minutes, 10 procedures per course, every day.
Results and discussion. As a result of examination, it was found that complaints of dry mouth, difficulty on swallowing of dry food and need to take some water after it were in all patients, recurrent parotitis were noted in 34 patients (81%). Complaints of dry eyes and sense of"sand" were presented in 40 patients (95%). Periodic arthralgia was observed in 36 patients (85,7%), periodic dysphagia - 6 patients (14%).
The enlargement of submandibular, infraauricu-lar and cervical lymph nodes was observed in 27 patients (64%). Raynaud's syndrome was observed in 15 patients (35.7%).
All patients had precervical caries of various degree of severity and partial adentia. The mucous membrane of the oral cavity in all patients was dry, hyperemic, there were cracks in the corners of the mouth, and in 3 patients there was a severe damage of the mucous membrane of oral cavity - expressed hyperemia of the mucous membrane, smooth, red mucous of tongue - "burning mouth". The Green-Vermillion index (index of hygiene of the oral cavity) was 5.4 ± 0.1, which corresponds to unsatisfactory level of hygiene of the oral cavity.
The decrease in salivation by Schirmer's test less than 10 mm/5 minutes (on average - 5.5 ± 0.05 mm) was observed in 40 patients, all patients had decrease in spontaneous salivation to 1.5 ml/15 minutes. The decrease in the content of lysozyme in saliva to 74 mcg/ml and SIgA to 0.34 g/l was detected.
A decrease in the amount of hemoglobin less than 110 g/l was detected in 28 patients (66.7%), an increase in ESR more than 15 mm/h in 10 patients (23.8%). Rheumatoid factor was detected in 19 patients (45%), antinuclear antibodies in low titre - in 32 patients (76%), anti-Ro/SS-A and anti-La/SS-B antibodies - in 17 patients (40%).
The results of investigation of oral cellular population are given in (Table 1). Before analyzing the changes in the composition of cell population, it should be emphasized that a large amount of dense
protein was detected in the oral liquid. As we can see from Table 1, before treatment macrophages (neutrophils) in the oral cavity were absent in all patients, which indicates the lack of nonspecific phagocytosis, that is, there is practically no antimicrobial protection in the oral cavity of these patients.
Perhaps it causes the changes in the microbial population. At the same time, there is a significant increase in the content of lymphocytes and "bare nuclei", which indicates the high activity of autoimmune inflammation.
Table 1.- Effect of laser irradiation on the cellular composition of oral cavity in patients with Sjogren's disease (%)
Group/Indicator Control group Before treatment After treatment
Lymphocytes 7.4% 32.12% 26.34%
Neutrophils 18.45% 0 17.76%
Epithelium 71.0% 58.78% 56.9%
"Bare nuclei" 1.47% 9.0% 0
The inclusion of laser therapy in complex treatment led to decrease in the hygienic Green Vermillion index, the content of IL-1 in serum, increase in the spontaneous salivation rate and the content of lysozyme in saliva (Table 2) more significantly than in the control group (Table 2), that significant increase in the amount of saliva and its bactericidal capacity. The obtained results indicate
Table 2.- Effect of complex treatment on the quantity and quality of saliva in
an additional inhibitory effect of laser therapy on autoimmune and inflammatory processes in the salivary glands, which are the pathogenetic basis of Sj D. Decrease in the content of IL-1, which is a systemic inflammatory mediator, may indicate a decrease in the intensity of the autoimmune inflammatory process in the salivary glands.
the level of interleukin-1, oral hygiene, patients with Sjogren's disease
№ Indicator Basic group (n = 21) Control group (n = 21)
1. Hygienic Greene-Vermillion index, before/after treatment, units 5.4 ± 0.1 4.0 ± 0.1* 5.4 ± 0.09 4.6 ± 0.07*»
2. Salivation rate, before/after treatment, ml/min 0.15 ± 0.01 0.26 ± 0.02* 0.15 ± 0.02 0.21 ± 0.01*»
3. Lysozyme content in saliva, before/after treatment, mcg/ml 75.0 ± 0.7 91.5 ± 0.9* 74.7 ± 0.6 86.1 ± 0.6*»
4. SIgA concentration in saliva, before/after treatment, g/l 0.34 ± 0.03 0.46 ± 0.04* 0.33 ± 0.02 0.43 ± 0.03*
5. IL-1 concentration in blood, before/after treatment, pg/ml 19.7 ± 0.1 14.2 ± 0.2* 19.6 ± 0.2 16.6 ±0.3*»
Notes: * - the significance of difference in the group before and after treatment, p < 0.05;
- the significance of difference after treatment in basic and control groups, p < 0.05.
Reduction of tension of autoimmune processes positively affects the state of protective capabilities of the oral cavity. This is evidenced by the appearance of neutrophil cavity in the cell population of the oral cavity (Table 1). In addition, the inhibition of autoimmune reactions by laser irradiation of the region of parotid gland contributes to decrease in the intensity of inflammatory processes (decrease in the content of lymphocytes), and evidence of inhibition of autoimmune reactions is the disappearance of "bare nuclei" from the cellular population of the oral cavity.
Conclusions. Thus, Sjogren's disease is characterized by obligate damage of mucous membrane of the oral cavity and teeth due to the autoimmune process in the glands of the external secretion (salivary and lacrimal). The application of laser therapy on parotid glands in the complex treatment of Sjogren's disease potentiates the positive effects of systemic therapy, greatly reduces the subjective and objective manifestations of xerostomia, achieves more significant increase in salivation, improvement of the protective properties of saliva and oral hygiene (reduction of Green-Vermillion index), and also increasing of oral mucous membrane resistance.
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