efficiency of laser therapy applied in labial traumatism

Braz Dent J 15 (Special issue) 2004

Laser therapy for labial traumatism SI-29

Efficiency of Laser Therapy Applied in LabialTraumatism of Patients with Spastic Cerebral Palsy

Luciano Artioli MOREIRA1

Maria Teresa Botti Rodrigues SANTOS2

Vanessa Ferreira CAMPOS2

Walter João GENOVESE3

1Laser Disciplines in Dentistry, Implantodontics and Integrated Dentistry Clinic,2Discipline for Patients with Special Needs,

3Laser and Pediatric Dentistry,University of Cruzeiro do Sul (UNICSUL), São Paulo, SP, Brazil

The aim of this study was to report the effectiveness of laser therapy applied to traumatic labial injury of patients with spastic cerebralpalsy. We report two cases of patients with internal mucosa and lower lip traumatism caused by oral reflex automatism with spastic tonicbite and lower lip interposition. One patient presented extensive lower lip ulceration, loss of tissue, crusty and hemorrhagic areas, withincreasing pain and spasticity. The other patient presented local congestion signs, extremely enlarged tissue growth and increased labialvolume. Laser therapy was applied to all injured areas, with a low-potency diode InGaAlP laser [685 nm Quasar® (Dentoflex), 190 J/cm2, with a 24-h interval between the first and second administration, and a 7-day interval between the two subsequent ones. At firstre-evaluation, 24 h later, there was a striking reduction in inflammation, a decrease in vascular congestion, and a reduction of theulcerated area with spasticity and pain reduction. At the 14-day re-evaluation, significant clinical differences in the advanced healingprocess were seen. Low-intensity laser showed to be effective in traumatic soft tissue treatment in cerebral palsy patients by acceleratingthe healing process, reducing secondary contamination, promoting analgesia; thus, it can be an important tool in the treatment of thesepatients.

Keys Words: cerebral palsy, muscle spasticity, automatism, laser therapy.

Correspondence: Dr. Luciano Artioli Moreira, Av. Dr. Ussiel Cirilo 225, UNICSUL, 08060-070 São Paulo, SP, Brasil. Tel: +55-11-6137-5744, Fax:+55-11-5585-9547. e-mail: [email protected]

ISSN 0103-6440

INTRODUCTION

Cerebral palsy belongs to a heterogeneous groupof non-progressive motor disorders caused by chroniccerebral lesion that may originate in the prenatal orperinatal periods or in the first years of life. The fourmain subtypes of cerebral palsy are spastic, athetoid,ataxic and mixed; the spastic subtype is the most com-mon. The motor disorder may vary from light difficul-ties in motor control to severe spasticity in all limbs,manifesting by coordination deficiencies of muscularactions and sensation deficiency, which is responsiblefor traumatism in soft tissues (1).

There are several secondary diagnoses associ-ated with cerebral palsy: epilepsy (25-33%), mentaldeficiency (50%), delay in the acquisition of speech,hearing loss and behavioral disorders. The high fre-

quency of convulsions and cognitive and sensorialperception deficiencies among patients with cerebralpalsy suggests that these disorders have a commonorigin or are related (2).

The persistence of primitive oral reflexes, con-sidered pathological after 6 months of age, has a patho-logical value and generally results from cerebral lesions(3). The pathological bite reflex prevents the develop-ment of elaborated mandibular, labial and tongue move-ments (4).

Spasticity is a frequent disorder in congenital oracquired central nervous system lesions and affectsmillions of people worldwide (5). It could be the singlecause of incapacity, affecting the musculoskeletal sys-tem and limiting normal motor function. It initiallyhinders the comfortable positioning of the individualand impairs daily tasks such as eating, locomotion,

Braz Dent J (2004) 15 (Special issue): SI-29-SI-33


L.A. Moreira et al.SI-30

transfer and hygiene. When not treated, it causes con-tractions, rigidity, luxation, pain and deformities (6-8).

Laser energy, when deposited on tissues, causesreactions of a physiological nature. In the organism, theinteraction of low-intensity radiation constitutes theenergetic incorporation contained in the laser lightbeam on the radiated tissues. The consequences ofthese interactions are 1) primary effects, subdividedinto biochemical, bioelectrical and bioenergetic; 2)secondary effects that stimulate the microcirculationand cellular trophism; 3) therapeutic effects, with anal-gesic, anti-edematous and healing results (9).

The therapeutic action of the low-intensity laserresides in the granulation action of the mast cells andincrease in histamine quality, causing local changesrepresented by vasodilatation and increase in vascularpermeability, acting on prostaglandins, inhibiting andblocking the action of the cyclooxygenase enzyme,thus, having an anti-inflammatory action. Simulta-neously, it promotes bio-stimulation of the tissuesthrough the increase of the cellular energy upon theincrease of ATP production (9).

This report describes the oral findings of twochildren with a diagnosis of spastic cerebral palsy treatedin the Discipline for Patients with Special Needs of theDentistry Course of the University of Cruzeiro do Sul.

CASE REPORT

The patients LRS (patient 1), female, leukoder-mic, five years and 11 months old, and KPOT (patient

2), male, leukodermic, two years and four months old,both with a diagnosis of severe spastic cerebraltetraparesis palsy, were referred to the Dental Clinic forPatients with Special Needs of the University of Cruzeirodo Sul, presenting traumatic lesion in the lower-lipregion, but with different clinical aspects.

This study was approved by the Research Ethi-cal Committee of the University of Cruzeiro do Sul andinformed written consent for participation in the studywas obtained from those responsible.

In the physical examination of patient 1, thepresence of a nasogastric tube and lower-lipparafunctional bite habits were observed. As a result offrequent traumatism, the lip presented extensive ulcer-ation, with loss of substance, crusty and hemorrhagicareas, internally surrounded by hyperkeratotic plaque(Figure 1). This leads to pain and a consequent increaseof the spasticity, in addition to the risk of local and/ordisseminated infection.

Due to the severe neurological state, the extrac-tion of the deciduous maxillary incisors was chosen(Figure 2), followed by a laser therapy protocol.

In the physical examination of patient 2, micro-cephaly, absence of cervical control, low weight/stat-ure development, severe spasticity, retardation in theneuropsychomotor development without steadying thelook or reacting to sounds, severe respiratory discom-fort, presence of important snoring, the use of nocturnaloxygen supplementation and gastromatization wereobserved (Figure 3). His previous medical history in-cluded emergency c-section birth, with parturient in

Figure 1. Extra-oral traumatic ulcer aspect in the lower lip ofpatient 1.

Figure 2. Intra-oral aspect of the surgical wound post-extractionof the deciduous maxillary incisors of patient 1.



cardio-respiratory arrest due to eclampsia. He receivedApgar 0/2/3, evolving with severe asphyxia, and wasintubated for 2 months. During the hospital stay, hepresented pneumonia, septicemia and convulsive syn-drome with difficult control. At that time, a gastronomywas performed.

In the specific clinical examination, severe res-piratory discomfort was observed, responsible for thelabial traumatism, since during the respiratory move-

ments, the child made friction movements with thetongue against the maxillary incisors and suction of thelower lip, in addition to the oral automatism of a reflex-ive nature with a tonic bite and inter-positioning of thelower lip between the incisive surfaces. There weresigns of local congestion, exuberant tissue growth, andincrease in labial volume, which further favored localtraumatism (Figure 4). Extraction of the four centraldeciduous incisors was chosen.

Laser therapy was applied on the injured loca-tion for both patients, with InGaAlP low-intensity laser(Quasar®, Dentoflex, São Paulo, SP, Brazil), energeticpower and deposition density of 190 J/cm2 in sweep,with a 24-hour interval between the first two applica-tions and a 7-day interval for the other two applications(Figure 5).

Figure 3. Frontal view of patient 2 presenting localized increasein the lower lip.

Figure 4. Intra-oral traumatic ulcer aspect of patient 2.

Figure 5. Application of InGaAlP laser on traumatic ulcers in both patients.


L.A. Moreira et al.SI-32

RESULTS

In the first re-evaluation, 24 h later, clear regres-sion of the inflammatory process with a reduction of theulcerated area, now covered by fibrous pseudomem-brane, was observed in patient 1 (Figure 6). The care-takers reported a reduction in spasticity and pain, aswell as improvement of the clinical condition. Forpatient 2, a significant reduction in the inflammatoryprocess, reduction of vascular congestion, translated bythe pinkish coloring of the circum-neighboring tissue,and facilitated breathing due to the reduction of thelabial volume was observed (Figure 7). The caretakersmentioned that the child had a 12-h revitalizing sleepwithout crying episodes.

In the last re-evaluation 14 days later, a signifi-cant difference in the advanced repair process in bothcases with a return to normality was observed (Figure8).

DISCUSSION

The multi-professional treatment of individualswith cerebral palsy includes professionals from allhealth areas, including the dentist, with the main objec-tive of rehabilitating these patients. Many times, theindicated therapeutic treatment is concentrated on thequality of life.

For patients with a diagnosis of severe spasticcerebral tetraparesia palsy, the rehabilitation team acts

Figure 6. Extra-oral traumatic ulcer aspect of patient 1 after 24hours.

Figure 7. Intra-oral aspect of the lower lip lesion of patient 2 after24 hours.

Figure 8. Extra-oral aspect of the lower lip of patient 1 after 14 days.



to minimize the deleterious effects of the severe neuro-logical injury by means of physiatric, physiotherapeu-tic, speech therapy, acupuncture, and medication treat-ments, among others.

It is up to the dentist to promote adequate dentaltreatment for extremely painful situations such as trau-matic soft tissue lesions in the oral cavity resulting fromthe presence of primitive pathological reflexes, as de-scribed by Schuberth (3).

Spasticity interferes in eating and hygiene (5),and promotes pain in the involved musculature (6). Oneof the treatment possibilities for spasticity in the masti-cation musculature is the chemical block with botulintoxin (7), but this therapeutic resource is not accessibleto all spastic patients due to its high cost.

Frequently, the result of the association of theneurological lesion, spasticity and the presence of patho-logical reflexes is the traumatism of the oral tissues. Anew therapeutic alternative for these patients is lasertherapy. The therapeutic property of the low-intensitylaser involves analgesic, anti-inflammatory and bio-stimulating actions considering the increase of the ac-tivity in the radiated tissues. According to Genovese(9), the bio-stimulating effect is the result of the in-crease in fibroblasts, vascular regeneration, increase inre-epithelization due to the increase in the rhythm ofcellular division. We were able to detect a clear regres-sion of the inflammatory process, with a reduction ofthe ulcerated area and reduction of the vascular conges-tion within a short period, certainly due to the anti-inflammatory and bio-stimulating effect of the laser.

Since the objectives of modern dentistry are tore-establish contour, function, and comfort, regardlessof the atrophy, disease or lesion the individual presents,several techniques had to be developed to reach thisobjective. These patients presented a loss of tissuesubstance, severe pain, and risk of infection, factorsthat are sufficient to increase spasticity, allowing forthe maintenance of the vicious circle of pain/spasticity/

inflammation/infectious process.Which alternative treatment can be used for the

traumatic soft tissue ulcers in neurologically compro-mised patients incapable of responding to verbal com-mands and consequently with complete absence ofcooperation? It is up to the dentist to choose the ad-equate treatment of traumatic lesions present in patientswith neurological sequelae.

We conclude that the low-power laser is effi-cient in the treatment of soft tissue traumatism in pa-tients with neurological sequelae, due to the accelera-tion of the repair process, reducing secondary contami-nation, pain and discomfort, thus, constituting an im-portant tool in the treatment of individuals who do notpossess motor coordination, contributing to improve-ment of their quality of life.

REFERENCES

1. Badawi N, Watson L, Petterson B, Blair E, Slee J, Haan E,Stanley F. What constitutes cerebral palsy? Dev Med Child Neurol1998;40:520-527.

2. Kuban KCK, Leviton A. Cerebral palsy. N Engl J Med1994;20:188-195.

3. Schuberth LM. The role of occupational therapy in diagnosis andmanagement. In: Disorders of feeding and swallowing in infantsand children. Tuchman DN, Walter RS eds. San Diego: SingularPublishing Group; 1994. p 115-130.

4. Segovia ML. Interrelaciones entre a odontoestomatologia y lafonoaudiologia. 2nd edn. Buenos Aires: Panamericana; 1995.

5. Braun R, Bottle MJ. Treatment of shoulder deformity in acquiredspasticity. Clin Orthop 1999;368:54-65.

6. Hinderer S, Gupto S. Functional outcome measures to assessinterventions for spasticity. Arch Phys Med Rehabil 1996;77:1083-1089.

7. Mall V, Heinen F, Linder M, Philipsen A, Korinthenberg R.Treatment of cerebral palsy with botulinum toxin A: Functionalbenefit and reduction of disability. Pediatr Rehabil 1997;1:235-237.

8. Teive HG, Zonta M, Kumagai Y. Tratamento espasticidade. ArqNeuropsiquiatr 1998;56:852-858.

9. Genovese WJ. Laser de Baixa Intensidade. AplicaçõesTerapêuticas em Odontologia. São Paulo: Lovise; 2000.

efficiency of laser therapy applied in labial traumatism

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