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Low-energy laser therapy in oral mucositis

Low-energy Laser Therapy in Oral Mucositis
César Miglioratia, Celso Massumotob, Fernanda de Paula Eduardoc,Karin Praia Mullerd, Teresa Carrierie, Patrícia Haypekf, Carlos de Paula Eduardog a Hospital Sírio Libanês, São Paulo, Brazil.
b Hospital Sírio Libanês, São Paulo, Brazil.
c Sociedade de Odontologia a Laser, São Paulo, Brazil.
d Faculdade de Odontologia da Universidade de São Paulo, Brazíl.
e Sociedade de Odontologia a Laser, São Paulo, Brazil.
f Faculdade de Odontologia da Universidade de São Paulo, Brazil.
g Faculdade de Odontologia da Universidade de São Paulo, Brazil.
Purpose: The use of high-dose chemotherapy as part of the preparative regimen for stem cell transplantation is associated
with mucosal damage. Laser irradiation of the oral, mucosa may help to decrease the severity of mucositis. This pilot trial was conducted to evaluate the usefulness of low-energy laser therapy in the control of pain associated with oral mucositis after stem cell transplantation or high-dose chemotherapy.
Materiais and Methods: Eleven patients with the diagnosis of chronic myelogenous leukemia (n=4), non- Hodgkin’s
lymphoma (n=3), acute myelocytic leukemia (n=1), and other malignancies (n=3) were submitted to high-dose chernotherapy for myeloablation. Seven patients received autologous stem cell transplantation two from allogeneic sources, and two were given high-dose chemotherapy only. The oral cavity of all patients was examined by an oral medicine specialist during the pretransplant and prechemotherapy work-up. The patients received irradiation with the mucolaser daily until post- transplant day 5. The entire oral mucosa was treated with a final energy density of 2J/cm2. Mucositis was clinically evaluated according to the WHO scale, and pain was measured by a visual analogue scale (VAS).
Results: The laser treatment was well tolerated by the patients. Two patients had mucositis grade I-II, 8 patients had grade
III-IV, and 1 patient had none. None of the patients had the maximal pain score. Six patients had grade 0-3 and 5 patients had grade 5-8 by VAS. The majority of patients associated the daily application of laser with prompt pain relief.
Conclusion: The use of low-energy laser therapy may play a role in the control of pain associated with oral mucositis. In
order to evaluate the efficacy of laser therapy in the prevention of mucositis after stem cell transplantation, a randomized Key words: bone marrow transplantation, laser therapy, oral mucositis, high dose chemotherapy.
J Oral Laser Applications 2001; 1:97-101 Submitted for publication:17.04.01; accepted for publication: 11.06.01 High-dose chemotherapy followed by stem cell followed by atrophy of the mucosa and ulceration transplantation is the therapy of choice for a variety that may be followed by bleeding and intense pain, of hematological diseases and solid tumors. Unfor- as discussed by Sonis.16 Oral mucositis appears tunately, the preparative regimen is associated with during the second week of chemotherapy and shows damage of the gastrointestinal epithelium and hema- its peak between post-transplant days 7 and 11. The topoietic cells from the bone marrow. Following the oral mucositis may change the patients’ quality of epithlelial damage, a high incidence of oral mucositis life leading to decreased caloric intake and increased use of narcotic drugs for pain relief.
Oral mucositis presents as an erythematous process Mester et al18 observed a decreased healing time in rats after treating the wounds with low-level laser was maintained 20,000/uL at all times with irradiated therapy (LLLT). LLLT can increase the protein (25 Gy single dose) platelet concentrares.
synthesis in cells and the endorphin release by the Preparative regimen: All patients received busulfan
(BU) 4mg/Kg/dx4 days (from days -5 to -2) followed This pilot trial was initiated to evaluate the useful- by cyclophosphamide (120 mg/kg). Dilantin was ness of LLLT in controlling pain associated with oral given for seizure prophylaxis during busulfan mucositis after stem cell transplantation.
High Dose Chemotherapy (HDC)
Eleven patients referred to the Hospital Sirio Libanês Two patients received HDC only. Patient number 8 was treated for NHL with I-phosphamide 1.2g/m2 X February 2001 were enrolled in the study. The 5 and VP-16 150mg/m2 for 3 days. Patient number patients’ characteristics and disease status at the 10 was treated for a lymphangiosarcoma with time of transplant and/or chemotherapy are doxorubicin 75 mg/rn2 and I-phosphamide 1.8g/m2 Transplant Preparation
Oral Examination
Colony stimulating factor: All patients received
The oral cavity of all patients was examined by an granulocyte colony-stimulating factor (G-CSF) oral medicine specialist before the preparative beginning the day after PBSC infusion. All patients regimen; all patients received information regarding received a combination of teicoplanin and oral hygiene. They were given a mouthwash, a ceftazidime whenever the absolute neutrophile count toothpaste, an extra- soft toothbrush, and a lubricant (ANC) was lower than 500/ul or when fever gel (Lacled Laboratories, California, USA) to developed. All patients were screened weekly for cornpensate for possible xerostomia. All patients hematologic CMV antigenemia from day 0 to day signed a consent form before the inclusion in the Apheresis was performed using a cell separatorFenwall, with 10 to 12 L of blood processed during Laser Application: The patient’s entire oral mucosa
each collection procedure at 50 mL/min. Apheresis was treated with the mucolaser (GaAlAs laser, started during the CD34+ cells peak. Platelet count MMOptics São Carlos, Brazil). The parameters used Fig 1 Oral mucositis of the lateral border of the tongue in a bone
marrow transplant patient. Day 12 post marrow infusion.
were 780 nm wavelength and an output power of oncological diseases and increased the success of 60 mW, giving a final energy density of 2 J/cm2. The bone marrow transplantation (BMT). However, most tip of the laser device roughly touched the oral of the patients (70% to 80%) develop severe oral mucosa for a total of 35 min per session. Daily sessions beginning on day -5 were performed in ln the present study, we have presented evidence each patient. Treatrnent was interrupted only if that GaAlAs laser therapy may play a role in the patients refused the application or in case of nausea/ control of pain during the process of mucositis in vomiting episodes. Applications continued through BMT patients. Previous studies have indicated that post-transplant day 5. The presence and severity of laser therapy may have an analgesic effect on mucositis was clinically evaluated using the WHO tissues.6,9,10,15 The mechanism involved in pain scale, and pain was measured by using a visual control is still not well understood. However, it is speculated that the modulation of nociception bymodification of nerve conduction rnay be improvedby the local release of endorphins and enkephalins.19 The treatment protocols of the present study popu-lation included high-dose chemotherapy, a known Patients tolerated the laser irradiation well. Applica- mucositis inducer. Despite the development of oral tions were not performed in a few instances because mucositis, all patients tolerated the treatment well of nausea or vomiting, but this did not interfere with and none developed the maximal pain intensity on the completion of the entire protocol for all patients.
Two patients developed mucositis grade I-II, 7 Several studies have demonstrated evidence that patients had grade III-IV, and one patient developed laser therapy may be beneficial in the healing of tissues.7,8,15.20,22,23 Although this was not the main None of patients had the maximal pain score (10).
focus of the present study, none of the 11 patients Six patients had grade 0-3 and five patients had had to interrupt their treatment because of oral grade 4-8 (severe) according to the VAS. The mucositis and no complications of infection or majority of patients associated the daily application bleeding were observed. The encouraging results of laser on the oral mucosa with prompt pain relief.
from this pilot trial led us to initiate a randomizedcontrolled trial to better understand the role of LLLTin the control and severity of rnucositis after stem DISCUSSION
cell transplantation and high-dose chernotherapy.
The use of high-dose chemotherapy followed bystem cell support has allowed for a better control of Fig 2 Extensive oral mucositis lesion on the tongue of a patient
Fig 3 Same patient six days later. The tongue was treated with
who received allogeneic bone marrow transplant. The patient low intensity laser daily. Observe the healing process. There is only mild erythema on the tongue and the patient is free of pain.
7. Longo L, Evangelista S, Tinacci G, Sesti AG. Effect of diodes- laser silver arsenide-aluminiurn (Ga-Al-As) 904 nm on healing of experimental wounds. Lasers Surg Med 1987;7:444-447.
We conclude that LLLT rnay play a role in the control 8. Mester E, Mester AF, Mester A. The biomedical effects of laser of pain in oral mucositis after stem cell transplantation.
application. Lasers Surg Med 1985;5:31-39.
9. Mezawa S, lwata K, Naito, Kamogawa H. The possible effect of ACKNOWLEDGMENTS
soft-laser irradiation on heat nociceptors in the cat tongue. Arch Centro de Oncologia do Hospital Sírio Libanês, São Paulo, Brazil; 10. Pimenta HM. Laser em Medicina e Biologia. São Paulo: ROCA SOL (Sociedade de Odontologia a Laser), São Paulo, Brazil.
11. Silva NMM, Cecchini RCM, Eduardo CP. Aplicações clínicas do soft laser em odontologia. Rev paul Odont 1992;14:30-32.
12. Taube S, Pironen J, Ylipaavalniemi P. Helium-neon laser therapy REFERENCES
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