Effects of low-level laser treatment on mouth dryness.

Abstract

Mouth dryness (MD) is usually followed by inadequate mechanical cleaning of the mouth and decrease in the levels of salivary antimicrobial proteins (including secretory immunoglobulin A (sIgA)). It is accompanied by difficulties during speaking and food swallowing, with an unpleasant taste, burning sensations in the mouth and higher susceptibility to oral diseases. Low-level laser treatment (LLLT) can intensify cell metabolism and its application on salivary glands could improve salivation. The purpose of this study was to evaluate the effects of LLLT on salivation of patients suffering from MD. The study included 17 patients with MD. Their major salivary glands were treated with low intensity laser BTL2000 on 10 occasions. The whole unstimulated and stimulated saliva quantities were measured just before the 1st, after the 10th and thirty days following the last (10th) treatment. In the samples of unstimulated saliva concentrations of sIgA were estimated by using ELISA method and its quantity in the time unit was calculated. The visual analogue scale (VAS) score was used to assess burning and/or pain intensity at these three time points. Statistical tests revealed significant salivation improvement quantitatively and qualitatively, i.e. increase in the quantity of saliva and sIgA. VAS score was also significantly improved and no side effects were observed. Conclusions: According to the results of this study, application of LLLT to xerostomic patients' major salivary glands stimulates them to produce more saliva with better antimicrobial characteristics and improves the difficulties that are associated with MD. This simple non-invasive method could be used in everyday clinical practice for the treatment of MD.

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Coll. Antropol. 34 (2010) 3: 1039–1043
Original scientific paper
Effects of Low-Level Laser Treatment on Mouth
Dryness
Danica Vidovi} Juras1,2, Josip Luka~3, Ana Ceki}-Aramba{in1,2, An|elko Vidovi}4, Ivana Canjuga2,
Miroslav Sikora5, Andreja Carek2and Mario Ledinsky3
1Dental Clinic, Zagreb University Hospital Center, Zagreb, Croatia
2School of Dental Medicine, Zagreb University, Zagreb, Croatia
3»Sestre milosrdnice« University Hospital, Zagreb, Croatia
4Dubrava University Hospital, Zagreb, Croatia
5Osijek University Hospital Center, Osijek, Croatia
A B S T R A C T
Mouth dryness (MD) is usually followed by inadequate mechanical cleaning of the mouth and decrease in the levels of
salivary antimicrobial proteins (including secretory immunoglobulin A (sIgA)). It is accompanied by difficulties during
speaking and food swallowing, with an unpleasant taste, burning sensations in the mouth and higher susceptibility to
oral diseases. Low-level laser treatment (LLLT) can intensify cell metabolism and its application on salivary glands
could improve salivation. The purpose of this study was to evaluate the effects of LLLT on salivation of patients suffering
from MD. The study included 17 patients with MD. Their major salivary glands were treated with low intensity laser
BTL2000 on 10 occasions. The whole unstimulated and stimulated saliva quantities were measured just before the 1st,
after the 10thand thirty days following the last (10th) treatment. In the samples of unstimulated saliva concentrations of
sIgA were estimated by using ELISA method and its quantity in the time unit was calculated. The visual analogue scale
(VAS) score was used to assess burning and/or pain intensity at these three time points. Statistical tests revealed signifi-
cant salivation improvement quantitatively and qualitatively, i.e. increase in the quantity of saliva and sIgA. VAS score
was also significantly improved and no side effects were observed. Conclusions: According to the results of this study, ap-
plication of LLLT to xerostomic patients’ major salivary glands stimulates them to produce more saliva with better
antimicrobial characteristics and improves the difficulties that are associated with MD. This simple non-invasive me-
thod could be used in everyday clinical practice for the treatment of MD.
Key words: low-level laser treatment, mouth dryness, secretory immunoglobulin A
Introduction
Mouth dryness (MD), dry mouth, hyposalivation and
xerostomia are common names for chronic reduction in
salivary glands secretion. It represents the state associ-
ated with numerous causes when the patient produces
less than 1.5 ml of whole saliva over a 15 minute period
without stimulation1. According to epidemiological stud-
ies, 10–47% of the population2, depending upon diagnos-
tic method, suffer from MD.
MD can have a significant adverse effect upon oral
health and quality of life1.It is often accompanied by dif-
ficulties with speaking, chewing, food swallowing, by im-
paired or diminished taste sensation3, and also by oral
burning or soreness4. Furthermore, there is an insuffi-
ciency of other important salivary functions including
mechanical cleansing action, control of pH, removal of
food debris from the oral cavity, remineralization, main-
taining the integrity of the oral mucosa and antimicro-
bial activity5. Impaired salivary functions and decrease
in the levels of salivary antimicrobial agents, including
secretory immunoglobulin A (sIgA), lead to higher sus-
ceptibility to oral infections, rampant caries6and perio-
dontal diseases7. The treatment of MD remains very
unsatisfactory1. It is primarily palliative, with emphasis
on the use of saliva substitutes4. These are often not
completely successful and systemic sialogogues, which
are associated with risks of side effects as well, have not
1039
Received for publication May 20, 2009

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been shown to conclusively improve salivary function8.
Therefore, new, efficient and safe solutions are required.
Numerous studies have shown beneficial effects of
low-level laser treatment (LLLT) on biological tissues. Its
mechanism of action is based on absorption of laser light
by tissue and consequential enhanced synthesis of ade-
nosine triphosphate9, i.e. on increase of the energy avail-
able to cells. Therefore, at adequate wavelength, inten-
sity and dose, LLLT is capable to achieve many advanta-
geous effects such as increased cell proliferation and col-
lagen production10, accelerated collateral circulation and
enhanced microcirculation11, accelerated tissue repair12,
promoted nerve regeneration or pain relief13. Anti-in-
flammatory, antiedematous, analgesic14and immunomo-
dulating15as well as many other desirable effects of
LLLT are also well known. Moreover, there are no con-
traindications reported for its use in dentistry and no
side effects associated with the use of LLLT have been
reported16.
Since the usefulness of LLLT has been shown in the
management of numerous diseases and conditions, we
assumed that it could be useful in MD as well. The aim of
this study was to find out whether LLLT of the MD pa-
tients’ salivary glands can result in salivation improve-
ment. Particular attention was paid to the potential of
LLLT to increase salivary flow rates, to induce synthesis
of sIgA and to facilitate accompanied subjective difficul-
ties.
Patients and Methods
The Ethics Committee of School of Dental Medicine,
Zagreb University, Zagreb, Croatia, approved the study
protocol. Written informed consent according to Helsinki
II Agreement was obtained from each participant. Seven-
teen patients (two men and fifteen women, mean age
68.8±12.2 years) diagnosed with MD on the basis of sali-
vary flow measurement voluntary participated in the
study, conducted at the Department of Oral Diseases,
Dental Clinic, Zagreb University Hosputal Center and
School of Dental Medicine, Zagreb University.
At the time of the study all the participants were
non-smokers and without clinical signs and symptoms of
oral diseases and conditions other than MD. MD was di-
agnosed when subjects produced less than 1.5 ml of
whole unstimulated saliva over a 15 minute period1.
None of them were taking any medication influencing
salivary secretion at the time of the study.
Patients´ major salivary glands were treated with low
power semiconductor diode laser (BTL-2000, Prague,
Czech Republic) by using infrared probe/diode (energy
density 1.8 J/cm2, frequency 5.2 Hz, output power 30
mW) on 10 occasions. LLLT was performed five days per
week for two consecutive weeks. Each parotid gland was
exposed for 5 minutes; submandibular glands were ex-
posed for 2 and sublingual for 1 minute per treatment.
The exposition of parotid and submandibular glands was
performed extraorally and sublingual glands intraorally
with the laser diode approximately 5 mm far from sur-
face over glands anatomic sites. In order to cover the
whole area of the glands treated, slow circulating move-
ments were performed during the treatment. Energy
dose delivered to each parotid gland was 7.2 J, to each
submandibular gland 2.88 J and to sublingual gland 1.44
J per treatment. Hence, total energy dose delivered in a
patient session was 23.04 J and the accumulated energy
delivered on the whole in 10 sessions was 230.4 J.
The whole unstimulated and stimulated saliva were
collected and quantified just before the 1st, after the 10th
and thirty days following the last (10th) treatment. Each
time this was performed between 9–11 a.m., at least 2 h
after the last intake of food or drink. Under resting con-
ditions, while participants were sitting with head bent
slightly forward, just after saliva swallowing, partici-
pants spat whole unstimulated saliva every 60 seconds
into calibrated containers (0.1 ml) during five minutes.
Thereafter they were asked to rinse their mouths with 50
ml of 1% ascorbic acid solution for 60 seconds. After swal-
lowing, participants spat whole stimulated saliva, in an
equivalent way as unstimulated saliva, into other cali-
brated tubes for the next five minutes. Unstimulated and
stimulated salivary flow rates were recorded for each
participant and expressed in mililiters per five minutes.
The samples of unstimulated whole saliva were frozen
and stored at –20°C until used for sIgA determination.
sIgA concentrations were measured by using commer-
cially available indirect competitive enzyme immuno-
assay kit (Salivary SIgA EIA kit, Salimetrics, State Col-
lege, PA, USA). According to the manufacturer’s manual
the intra-assay precision was determined from the mean
of 10 replicates each (saliva samples) and coefficient of
variation (CV) ranged from 4.49% to 6.99% for the sam-
ples with high, medium and low concentrations of sIgA.
The inter-assay precision was determined from the mean
of average duplicates for 8 separate runs with the CVs of
8.65% for the samples with high concentration and 8.93
for the samples with low concentration of sIgA.
The quantities of salivary IgA secreted in 5 minutes
were calculated by taking in account sIgA concentrations
and volumes of unstimulated saliva secreted in 5 min-
utes.
Just after saliva collection, at the same three time
points, burning and/or pain intensity was assessed by us-
ing a 10 cm long visual analogue scale (VAS).
Statistical analysis
Normality of the distribution of variables was che-
cked with Shapiro-Wilks’ tests. Since all the variables fol-
lowed Gaussian distribution, we performed repeated mea-
sures ANOVA for testing the effect of treatment on vari-
ables determined at three time points (3x1 design). If
ANOVA proved to be significant, Tukey’s post-hoc tests
were performed to test the differences between single
time points. p<0.05 was considered statistically signifi-
cant. Data were analyzed using Statistica V6 (Statsoft,
Tulsa, USA).
D. Vidovi} Juras et al.: Laser in the Treatment of Mouth Dryness, Coll. Antropol. 34 (2010) 3: 1039–1043
1040

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Results
Statistical analysis revealed that LLLT improved par-
ticipants’ salivation quantitatively and quantitatively,
i.e. increased the quantities of saliva (Figures 1 a and b)
and sIgA (Figure 1c).
The quantity of unstimulated saliva gradually in-
creased during the study, from 0.6±0.3 mL/5min (X± SD)
just before the first LPLP , through 0.9±0.6 mL/5min af-
ter the 10thLLLT, to 1.1±0.8 mL/5min 30 day following
the last LLLT. It was significantly higher 30 days after
treatment when compared to baseline (Figure 1a).
The quantity of stimulated saliva was 1.4±0.6 mL/
5min (X±SD) at the beginning. It increased after the 10th
LLLT (2.3±1.0 mL/5min) and remained elevated 30 days
following the LLLT (2.4±1.3 mL/5min). Compared to
baseline, at both time points the increase was statisti-
cally significant (Figure 1b).
The quantity of sIgA in unstimulated saliva secreted
in 5 minutes just before the LLLT was 236.1±125.8
mg/5min (X±SD). Immediately after the 10thLLLT it was
higher (287.7±171.6 mg/5min), but this increase was not
significant. Thirty days after the 10thLLLT it measured
384.9±214.6 mg/5min, which was significantly higher
when compared to baseline (Figure 1c).
Intensity of burning and/or pain determined by VAS
was 4.8±3.1 cm (X±SD) at baseline, 2.2±2.1 cm immedi-
ately after the 10thtreatment, and 2.0±2.1 cm 30 days af-
ter the 10thtreatment. According to the participants’ re-
ports, the burning and/or pain intensity was reduced
significantly after the 10thLLLT and it remained signifi-
cantly lower 30 days after LLLT (Figure 1d). There were
no side effects reported during this study.
Discussion
Numerous studies have been performed with the aim
of investigating the possibilities of using low-level laser
in dentistry. Despite this fact, the efficacy of LLLT in pa-
tients suffering from MD has been scantily investigated
up to this point.
The results of our study prove the positive therapeu-
tic effect of the LLLT on xerostomic patients’ major sali-
vary glands and on concomitant burning and/or pain sen-
sations. By applying of the LLLT, it seems possible to
stimulate major salivary glands to produce more saliva
with better antimicrobial characteristics and to relieve
the difficulties related to MD and eventually improve
their quality of life. The fact that the advantages of LLLT
were observed just after the last (10th) treatment but also
in the follow up period of 30 days when they were even
D. Vidovi} Juras et al.: Laser in the Treatment of Mouth Dryness, Coll. Antropol. 34 (2010) 3: 1039–1043
1041
Fig. 1. a) The whole unstimulated saliva quantities measured before and after low-level laser treatment (LLLT) (effect of treatment
F(2.32)=5.614; p=0.008; *T1 vs. T3, p=0.006). b) The whole stimulated saliva quantities measured before and after LLLT (effect of
treatment F(2.32)=10.265, p<0.001; *T1 vs. T2, p=0.002, **T1 vs. T3, p<0.001). c) The quantities of salivary IgA in unstimulated sa-
liva measured before and after LLLT (effect of treatment F(2.32)=3.940, p=0.029; *T1 vs.T3, p=0.025). d) The burning and/or pain in-
tensity using visual analogue scale measured before and after LLLT (effect of treatment F(2.32)=15.827, p<0.001; *T1 vs. T2, p<0.001,
**T1 vs. T3, p<0.001). T1 – before the 1stLLLT, T2 – after the 10thLLLT, T3 – 30 days following the last (10th) LLLT. Data were ana-
lyzed with repeated measures ANOVA (analysis of variance) and Tukey’s post-hoc tests. Vertical lines denote 95% confidence intervals of
the mean.

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more pronounced proves that LLLT effects are prolonged
and indicates that, besides biostimulative, they also have
regenerative effect.
Although none of the few available study reports on
LLLT effect on salivary glands revealed similarly de-
signed study, some findings of those studies are impor-
tant for our results discussion. In the first experimental
study of the effect of Ga–As semiconductor laser on sali-
vary glands, which was carried out on rat submandibular
glands, Takeda17found an increase in the mitoses of duct
epithelial cells. Takahashi18proved regeneration of the
intralobular duct and acinus in rat submandibular gla-
nds after YAG laser irradiation. Simões19observed posi-
tive effects of LLLT on salivary flow rate and some sali-
vary parameters in rats. Lopes20stated that InGaAIP
laser was effective in patients with head and neck cancer
submitted to radiotherapy in prevention of radiother-
apy-induced xerostomia, oral mucositis and related pain.
In a double blind randomized trial Cowden21showed the
efficiency of He-Ne laser in the prevention of oral mu-
cositis and xerostomia induced by high dose chemo-
radiotherapy before autologous bone marrow transplan-
tation. Tuner22and Simões19published results showing a
fast response of the Sjögren's syndrome patients' glands
to laser irradiation and efficiency regarding MD and in-
flammatory process. Kats23reported high therapeutic ef-
ficiency of LLLT in treatment of chronic nonspecific
sialoadenitis resulting in rapid resolution of inflamma-
tory symptoms and pain, high salivation, longer remis-
sion and a recovery of the gland structure. Ross13re-
ported that LLLT results in nerve regeneration and this
could mean also in stimulation of parasympathetic secre-
tomotor innervation of the salivary glands. The above-
-mentioned reports are in accordance with our observa-
tions that LLLT is capable to increase saliva production.
The exact mechanism responsible for such effect of LLLT
on salivary glands and its secretion remains poorly under-
stood24. Almost certainly, future explanation of the mech-
anism underlying these effects will include the ability of
LLLT to increase the local-circulation through vasodila-
tation, to induce glandular cell proliferation, to improve
cell respiration/ATP synthesis and release of growth fac-
tors and cytokines25, to stimulate protein exocytosis26,
and to promote nerve regeneration13.
Petrek27found stimulatory effect of He-Ne laser on
the immune system of the patients suffering from chro-
nic tonsillitis. Among other effects, shortly after the ces-
sation of the treatment, he observed clinical improve-
ment and significant increase of sIgA which was followed
by increase of IgA serum levels after 4 weeks of fol-
low-up. Kucerová28reported an increased sIgA and the
pain diminishing following the He-Ne laser therapy after
molar extraction. Likewise, our results showed that LLLT
significantly increased sIgA and relieved patients’ symp-
toms. A possible explanation for the increase of sIgA is
that local laser irradiation intensifies the activation of B
lymphocytes, whose differentiation into plasma cells con-
tributes to an increase in immunoglobulin levels27,28. The
potential of LLLT to increase sIgA, the predominant im-
munoglobulin found in saliva29, could be of significant
importance. This is due to the fact that sIgA, character-
ized by its antiadhesive action against microorganisms,
is considered to be the main specific defence mechanism
in the oral cavity30.
Another important, analgesic effect of LLLT, also
demonstrated in this study, is in line with the findings re-
ported by many other authors16,20,21,23,25,31,32as well. Cur-
rent explanation of analgesic effect of LLLT, although it
hasn’t been completely clarified, is based on its possibil-
ity to enhance synthesis of endorphins and bradykinins,
to decrease c-fiber activity and to alter pain thresho-
ld16,25. Some authors hypothesized that this analgesic ef-
fect was mediated by serotonin and acetylcholine re-
leased centrally, and by histamine and prostaglandins re-
leased peripherally with the use of LLLT25,33.
None of the available reports, publised results of in-
ternational experimental and clinical research conducted
in the period longer than last thirty years, indicated any
true side effects associated with the use of low-level laser
light16. Our findings confirm these observations.
On the basis of our study results, we can conclude
that LLLT has been shown to be effective in treatment of
MD and free of any side effects. Since currently used
treatments of MD, including palliative short lasting sa-
liva substitutes and systemic siagogogues associated with
the risk of numerous side effects, are very unsatisfac-
tory1, LLLT seems to be superior and promising thera-
peutic solution. Although the results of our study indi-
cate positive effects of LLLT in patients suffering from
MD, further investigations with longer follow up period
and/or addition of placebo group are needed to determine
specificity and duration of beneficial effects and to ascer-
tain if this simple, non-invasive and free of side-effects
method could be introduced into everyday clinical prac-
tice as a routine procedure for the treatment of MD.
Acknowledgements
This study was supported by the Ministry of Science,
Education and Sport of the Republic of Croatia (Project
No. 065-0650445-0485).
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D. Vidovi} Juras
Department of Oral Disease, Dental Clinic, Zagreb University Hospital Center, Gunduli}eva 5, 10000 Zagreb, Croatia
e-mail: djuras@sfzg.hr
U^INKOVITOST LASERA NISKE IZLAZNE SNAGE U LIJE^ENJU SUHO]E USTA
S A @ E T A K
Suho}u usta (MD) redovito prati neadekvatno mehani~ko ~i{}enje usta i smanjenje koli~ine salivarnih antimikrob-
nih proteina (uklju~uju}i sekretorni immunoglobulin A (sIgA)). Tu su i pote{ko}e tijekom govora i gutanja hrane, neu-
godan okus, osje}aj pe~enja u ustima i ve}a sklonost prema oralnim bolestima. Tretman laserom niske izlazne snage
(LLLT) mo`e intenzivirati metabolizam stanica te bi njegova aplikacija na `lijezde slinovnice mogla pobolj{ati lu~enje
sline. Svrha je ovog istra`ivanja procijeniti u~inke LLLT-a na salivaciju bolesnika koji pate od MD-e. Sudjelovalo je 17
ispitanika. Velike `lijezde slinovnice bolesnika 10 su puta bile tretirane laserom BTL 2000 niske izlazne snage. Nepo-
sredno prije prvog, te nakon desetog i tridesetog dana nakon zadnjega, desetog tretmana mjerili smo ukupnu nestimuli-
ranu i stimuliranu slina. U uzorcima nestimulirane sline pomo}u ELISA-e odre|ivali smo koncentracije sIgA te izra-
~unali njegovu koli~inu u jedinici vremena. Uz pomo} vizualno-analogne ljestvice procjenjivali smo intenzitet pe~enja
i/ili boli u sve tri vremenske to~ke. Statisti~ka analiza rezultata otkrila je znatno pobolj{anje salivacije nakon LLLT-a.
Ono je bilo i kvantitativno i kvalitativno, tj. znatno je bila pove}ana koli~ina sline i sIgA. Rezultati mjerenja prema
ljestvici VAS tako|er su bili mnogo bolji, a nepo`eljni u~inci nisu uo~eni. Prema rezultatima ovog istra`ivanja, LLLT
velikih `lijezda slinovnica bolesnika s MD-om poti~e ih da proizvedu vi{e sline s boljim antimikrobnim karakteristi-
kama i olak{ava pote{ko}e koje prate MD-u. Ta jednostavna neinvazivna metoda ima potencijala da se uvede u svako-
dnevnu klini~ku praksu kao rutinski postupak za lije~enje MD-e.
D. Vidovi} Juras et al.: Laser in the Treatment of Mouth Dryness, Coll. Antropol. 34 (2010) 3: 1039–1043
1043