Low level lasers can be used to reduce oedema

1. INFRARED DIODE LASER THERAPY-INDUCED
LYMPHATIC DRAINAGE FOR INFLAMMATION
IN THE HEAD AND NECK
Luciana Almeida-Lopes1, Attilio Lopes2, Jan Tunér3 and R Glen Calderhead4
1: Collaborating Researcher, ElectroThermoPhotoTherapy Laboratory – UFSCar – Brazil; 2: Department of Oral Pathology,
College of Dentistry, University Camilo Castelo Branco, São Paulo, Brazil; 3: Private Dental Clinic, Grängesberg, Sweden; and
4: LG Biomedical, Tochigi and Japan Phototherapy Laboratory, Tokyo, Japan
Inflammation of many different aetiologies is a condition affecting almost 100% of all patients presenting at
dental clinics, and the complete management of inflammation is often extremely important before any orth-
odontic surgery can be carried out. The lymphatic system is one of the body’s main lines of defence against in-
flammation, with the lymph nodes playing an extremely major role. laser therapy, or LLLT, has become much
more common in dental offices, and is associated with pain attenuation, wound healing and anti-inflammatory
properties. The last of these is mediated amongst others by the effect of LLLT on the lymphatic system, which
has been shown to enhance lymphatic drainage concomitantly with increasing local blood flow to the treated
area. Infected areas and those with viral contamination have been suggested as contraindications for laser ther-
apy. The possibility of treating these difficult-to-manage entities through laser therapy-accelerated drainage of
theaffectedlymphaticsoffersanotherapproach.Althoughlymphaticdrainageisfrequentlyusedintheclinical
setting, its application in dentistry is less common than it should be. An illustrated review of the lymphatic sys-
tem of the head and neck is presented, with relevance to the use of infrared diode laser therapy in inducing lym-
phatic drainage in the management of inflammation associated with acute infectious processes such as
pericoronitis, endodontic abscesses, alveolitis and herpes. A case report is presented illustrating the success of
this therapeutic approach for labial herpes simplex. Infrared diode laser therapy-mediated lymphatic drainage
offers an interesting and efficacious approach in the management of infectious and contaminated areas, with-
out actually irradiating the areas themselves.
Key words: Lymphatic drainage, lymph nodes, endodontic disease, infrared laser therapy, pericoronitis,
alveolitis, herpes simplex, laser dentistry
Introduction
The therapeutic laser has been used since the 1980’s in
cases of inflammation, acting as a mediator in these pro-
cesses, activating the lymphatic flow in the irradiated re-
gion(1-5) in addition to stimulating the local autoim-
mune system of the patient.(6-8) Because of these proper-
ties, laser therapy has been successfully indicated for
lymphatic drainage in cases of inflammation in both
acute (exudative inflammation) and chronic (prolifer-
ative inflammation) cases. The present study reviews the
localization of the main palpable lymph nodes in the
head and neck, the function of each of the lymph node
networks, and presents a technique for the treatment of
cases of inflammation through the lymphatic drainage
stimulated by the application of laser therapy.
The lymphatic system
The lymphatic system consists of well-differentiated tis-
sue groups which are ultrastructurally distinct and
widely spread, ‘Lymph’ comes from the Greek via the
Latin ‘lympha’ and means ‘clear water’, which is what
the Ancient anatomists found during dissection in what
they believed were part of the venous system. The com-
plex system of lymphatic vessels has several functions. It
drains excess exvasated extracellular fluids back into the
blood circulation, is an important component of the
scavenging and homeostatic system, and a very impor-
tant component of the autoimmune system as part the
first line of defence of the body against viral or bacterial
attack. The lymphatic system not only acts as a filtration
system to trap and then destroy cellular debris from the
vascular system and connective tissue, it is also the main
repository and ‘superhighway’ for the various types of
lymphocytes to enable them to be recruited to any area
of the body where they are needed.
ORIGINAL ARTICLES
Addressee for Correspondence:
Luciana Almeida-Lopes DDS PhD.
Rua Tibães, 22-Jd. São Bento,
CEP 02525.030
Sao Pãulo,
Brazil
e-mail: lal@apcd.org.br
Manuscript received: December 2004
Accepted for publication: February 2005
© 2005 JMLL Ltd. Laser Therapy 14.2: 67-74 67

2. The lymph vessels start as closed end microvessels
which gradually join up, and enlarge as they do so to
form the main vessels that finally transfer the collected
lymph back into the blood vascular system at the left
subclavicular vein. The lymph vessels of the extremities
and trunk drain upwards against gravity using a semi-
passive propulsion method, but those of the head and
neck that are of particular interest in the current article
drain downwards with gravity.
Along the paths of the lymphatic vessels are found
clusters of circumscribed masses of differentiated tissue,
the lymph nodes. These are roundish, encapsulated
structures, with an outer cortex surrounding an inner
medulla, and are considered secondary lymphoid or-
gans.(9) The cortex is packed with lymphocytes, and the
medulla contains the ‘medullar cords’, cord-like masses
of T- and B- lymphocytes and plasma cells. The B-lym-
phocytes are related to humoral immunity, are mostly
of bone marrow origin, and are found mainly in the cor-
tical follicles, whereas the T-lymphocytes are related to
cellular immunity, are mainly of thymus origin, and are
found in the paracortical and medullar areas.(10) Lymph
nodes are also storage points for macrophage cells, par-
ticularly in the medullar area. Normal lymph nodes are
about the size of a pea; they are painless to palpation,
unruffled, movable and of a soft consistency.
Occasionally, in the role of lymph nodes as biolog-
ical filters, waste material builds up in a node or group of
lymph nodes, and they can succumb to the infection
they are designed to fight. The lymph vessels become
inflamed (lymphangitis) followed by inflammation of
the nodes themselves (lymphadenitis), and in serious
cases the lymph flow is obstructed and builds up behind
the affected nodes (lymphoedema). These processes pro-
duces swelling and pain, with the nodes themselves be-
coming hard, swollen and often severely painfully
palpable. This is where low incident levels of laser en-
ergy have proved extremely useful in controlling the in-
flammatory process, recruiting scavenger cells such as
neutrophils and macrophages into the area of inter-
est(11,12) and modulating their activities so that the ob-
struction is cleared and the lymphatics returned to nor-
mal, and enhancing local blood flow(13) to assist in
controlling and clearing the inflammatory response.
Lymph node nets in the head and neck
The main lymph node nets in the head and neck are: Oc-
cipital (Figure 1); Pre-auricular (Figure 2); Right and
Left Submandibular (Figure 3); Submental (Figure 4);
Lateral cervical (Figure 5); Deep superior cervical (Fig-
ure 6); Deep inferior cervical (Figure 7); Mastoid (Figure
8);andsupraclavicular(Figure9).(14) Themainpalpable
lymph node nets in the head and neck are: Occipital,
Pre-Auricular, Right and Left Submandibular, Sub-
mental, and Cervical (only the superior cervical nodes),
as observed in Figure 10.
ORIGINAL ARTICLES
68 L. ALMEIDA-LOPES ET AL.
Fig 1: The occipital lymph nodes.
Fig: 2: The preauricular lymph nodes.
Fig 3: The right and left submandibular lymph nodes.

3. ORIGINAL ARTICLES
LASER THERAPY-ASSISTED LYMPHATIC DRAINAGE 69
Fig 4: The submental lymph nodes.
Fig 5: The lateral cervical lymph nodes.
Fig 6: The deep superior cervical lymph nodes.
Fig 7: The deep inferior cervical lymph nodes.
Fig 8: The mastoid lymph nodes.
Fig 9: The supraclavicular lymph nodes.

4. Main Lymph Node Chains
A description will now be given of the main lymph node
chains, and their possible roles in dealing with infections
of the face likely to be encountered in dental practice
through laser therapy-assisted lymph node drainage.
Pre-auricular lymph nodes
The drainage area of these nodes is limited to the cutane-
ous surface, corresponding to the anatomical location of
temporomandibular joint (TMJ) and to the point of in-
sertion of the masseter muscle into the zygomatic arch.
Inflammation of these nodes can occur as a result of an
infection of or trauma to the TMJ, or it can represent the
presence of an impacted or enclosed mandibular third
molar, (retained mandibular third molar syndrome).
Iatrogenic pain caused by orthodontic treatment with
fixation apparatus, during and after treatment, can be
reduced or avoided with the application of laser in the
trigeminal passage. Figure 11 illustrates the laser irradi-
ation on these lymph nodes. Please note that the visible
light laser used in Figures 11 – 14 is to show the laser en-
ergy involvement over and around the irradiated nodes.
Actual treatment was performed with an 830 nm near
infrared GaAlAs diode laser, and appropriate eyewear
was worn by both the patients and clinician.
Mastoid lymph nodes
Formerly called the post-auricular nodes, these nodes
are topographically coincident with the occipitomastoid
suture, where inflammation of them indicates scalp in-
fection. They can be palpated with circular digital
movements around the mastoid apophysis and are gen-
erally easily felt because of the perfect location of the
bone structure. The mastoid lymph capillary nets have
nothing to do with the oral or dental structures, nor with
their respective sustaining tissues.
Submandibular lymph nodes
These are formed bilaterally in two symmetrical chains:
right and left. They indicate infection of, or neoplasm
formation on the surface of the mouth, tongue floor and
vestibular face of the lower lip. They are the most fre-
quently affected nodes in infections of the tongue, body
of the mouth, and the maxillary and mandibular molars.
Figure 12 demonstrates laser irradiation on these lymph
nodes.
ORIGINAL ARTICLES
70 L. ALMEIDA-LOPES ET AL.
Fig 10: The main palpable lymph node nets in the head
and neck.
Fig 11: Laser therapy demonstrated on the preauricular
lymph nodes. Note the protective eyewear worn
by the patient. In Figures 11 – 14, please refer to
the text for the areas drained by the particular
nodes being irradiated, and the possible disease or
pathologicalentitiesassociatedwiththetherapy.
Fig 12: Laser therapy demonstrated on the
submandibular lymph nodes.

5. Submental lymph nodes
Swelling of these nodes indicates neoplastic alteration or
infection on the floor of the mouth, belly of the tongue
or mandibular incisors, or sialoadenopathies in the
glands of the region already mentioned. Detailed know-
ledge of the anatomy is essential for the therapist. These
nodes always precede acute inflammatory alterations of
the mouth, some of which can be very serious, such as
Ludwig’s angina. The submental chains converge to the
mediastinal area, and if an acute septic alteration is not
detected early enough, in rare cases the appearance of
mediastinitis can result. Figure 13 demonstrates laser ir-
radiation on these lymph nodes.
Cervical lymph nodes
The nodal cervical chains are divided, for methodologi-
cal purposes, into the superficial cervical and deep cervi-
cal nodes. Both can be upper or lower. The deep cervical
lymph nodes cannot be easily palpable and therefore are
of no semiological concern to the examiner, but the up-
per, both anterior and lateral, may be related to scalp in-
fection but rarely to mouth and pharynx infection
(Figure 14 shows laser irradiation on these lymph
nodes). The large volume of the trapezoid muscle does
not allow evaluation of the lymph nodes located in the
rear portion of the neck, but the chains located in the an-
terior portion of the neck, both in the supra- and in-
fra-hyoid regions, down to the clavicle, can be evaluated
by digital palpation, not only using the finger tips but
also by the bilateral palpation method, using the index
and middle fingers tips of both hands.
Altered lymph nodes of an inflammatory type
These are usually identified by an increased volume,
slight to extreme tenderness to the touch, mobile and
with a slight increase in temperature due to the infec-
tion-related inflammatory process. The volume increase
felt by palpation, however, does not always indicate a
true infection: sometimes it means the presence of a
lymph node which has suffered, at some point, a greater
demand of its activity because of an acute, but now ter-
minated, infection. The lack of any elevated tempera-
ture and tenderness allow for a differential diagnosis.
These are called residual lymph nodes, and do not re-
quire any intervention with laser therapy.
Case Report: Treatment of herpes simplex of the
lips (herpes labialis)
‘Cold sores’ on or around the lips, herpes labialis, are
caused by herpes simplex virus type 1 (HSV-1). This is
the most common herpes simplex virus among the gen-
eral population and is usually acquired in childhood, so
that by adulthood up to 90% of individuals will have an-
tibodies to HSV-1. Once the virus is acquired, it spreads
to nerve cells in the lips, mouth or face, and remains dor-
mant. It may intermittently reactivate and cause symp-
toms known as flares. Reactivation can be due to a
variety of conditions, such as overexposure to sunlight,
minor trauma, fever, stress, acute illness, and medica-
tions or conditions that weaken the immune system.
Herpes infections are also rather common after laser re-
surfacing of the face. The lymph nodes draining the ar-
eas affected by the lesions often themselves become
swollen and tender, aiding in the diagnosis of herpes
simplex-mediated inflammation.
Warning symptoms of , a tingling sensation, in-
creased sensitivity or burning may appear about 2 days
prior to the formation of the lesions. The lesions them-
selves can take several forms: s or a rash around the lips,
mouth, and gums; small vesicles filled with a clear, yel-
lowish fluid; blisters that form then break and ooze, or
are on a red, raised and painful area of the skin; or sev-
eral smaller blisters that merge to form a single larger
ORIGINAL ARTICLES
LASER THERAPY-ASSISTED LYMPHATIC DRAINAGE 71
Fig13: Lasertherapysimulatedonthesubmentallymphnodes.
Fig14: Lasertherapyillustratedonthecervicallymphnodes.

6. blister. If herpes labialis lesions remain untreated, they
usually subside in 1 – 2 weeks, but in cases where the pa-
tient exacerbates the lesions by constantly touching
them with the fingers or exploring them with the
tongue, or self-excoriation of the crust, they may en-
large and last for several weeks.
Figure 15a shows a young female patient in the
early phase of vesicle formation, particularly evident
just beneath the philtrum. Note also the two other less
evident sites of infection shown by the arrowheads. La-
ser therapy with an infrared diode laser at 830 nm, 70
J/cm2 per point, points treated over the affected
submental and sublingual lymph nodes. The patient
was treated in two sessions, with two days between ses-
sions, and Figure 15c shows the excellent result with the
major lesions on the upper lip never having reached the
crusting phase, and the lesions marked with arrowheads
in Figure 15a never having reached the vesicular stage.
This result should be compared with the best case result
of a 1-week resolution with topical and/or oral anti-
herpetic medication.
Discussion
The influence on lymphocytes of low incident levels of
laser energy was described by as early as 1978(15) and the
effect on the lymphatic system has since then been stud-
ied by several researchers. (16-21) Low incident levels of
laser and light energy have had reported antiviral ef-
fects(22) and also on reducing the tissue-damaging reac-
tive oxygen species production of immunologically-
stressed neutrophils(23) in addition to increasing and ac-
celerating their capacity to identify and move to targets
(chemotaxis), phagocytosis and internalization of these
targets.(24)
In the case of herpes simplex lesions, traditionally
these have been treated over the actual vesicles them-
selves,(25) applying the laser to the actual lesion. Al-
though success has been demonstrated with this
approach, there are concerns about enhanced activation
or even dissemination of viral cells. The authors have
been using the lymphatic drainage technique described
above for the past 6 years, avoiding the conventional di-
rect lesion irradiation technique. The advantage of the
lymphatic drainage technique presented here is the
avoidance of the activation of the microorganisms that
infect the lesion area, in case of highly contaminated le-
sions (as it is with the herpes in the vesicle phase), suppu-
rative acute apical lesions, or acute cases of pericoronitis
or alveolitis. This technique aims at activating the pa-
tient’s local immunity, as well as activating the drainage
of the region, allowing the patient to go through an ac-
celerated inflammatory phase with minor edema, and
consequently less pain and discomfort.(26,27)
ORIGINAL ARTICLES
72 L. ALMEIDA-LOPES ET AL.
Fig 15: Laser Therapy-assisted lymphatic drainage applied in
a case of herpes labialis in a young female patient.
a: Pre-therapy findings. Vesicular lesions can be seen
under the philtrum, but two prevesicular lesions are
identified with the arrowheads. b: Treatment of the
submental lymph nodes with a GaAlAs diode laser at
830 nm. The sublingual nodes were also treated. Note
the sterile plastic wrap over the laser handpiece. c: Af-
ter 2 treatment session, two days between sessions, the
result is excellent with almost total resolution of the
lesions. The vesicular lesions have not reached the
crusting stage, and the lesions marked with arrow-
heads in (a:) have not reached the vesicular stage.

7. Conclusions
This laser therapy-assisted lymphatic drainage tech-
nique is effective for the clinical treatment of inflamma-
tion in the facial and mouth areas, through activation of
the local drainage, reduction of oedema and increased
the blood flow rate and volume in the irradiated, com-
bined with restoration then acceleration of lymphatic
drainage. The ideal indication would be in those highly
contaminated acute processes, where the direct applica-
tion of laser energy could activate the microorganisms of
the region, exacerbating the infectious process, instead
of reducing it. The technique is easy to apply, painless,
well tolerated by all patients, even those with dento-
phobia, and has proved extremely safe and very effica-
cious.
Editorial Note:
The Managing Editor would like to acknowledge the
first class hand-drawn illustrations from Professor Atillo
Lopes, of the Department of Oral Pathology, College of
Dentistry of the University Camilo Castelo Branco in
São Paulo. Prof Lopes is an excellent medical illustrator,
as can be seen from the illustrations of the main lymph
node networks in this article. In the interests of cost,
however, these have been converted to half tone images
from the original colour illustrations, and have been
relabelled in English from the original Brazilian. Any
readers interested in seeing the original colour illustra-
tions in all their glory can do so on the internet at
www.lasertherapy-journal.com/atillo-illus.html. At the
same time, why not have a look at the journal website
(follow the link from the previous web page).
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