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Lasers in Medical Science

, Volume 30, Issue 6, pp 1805–1809 | Cite as

Effect of laser acupuncture on salivary flow rate in patients with Sjögren’s syndrome

  • Adriana Cafaro
  • Paolo Giacomo Arduino
  • Alessio Gambino
  • Ercole Romagnoli
  • Roberto Broccoletti
Brief Report

Abstract

Sjögren’s syndrome (SS) is a multisystem autoimmune disease characterized by hypofunction of the salivary and lacrimal glands, frequently relieved with symptomatic treatments, such as saliva substitutes, eye lubricants, and cholinergic stimulators. The aim of this pilot randomized placebo-controlled study was to estimate the effects of laser acupuncture on salivary flow rates in patients with severe hyposalivation due to SS. A prospective cohort of 26 female patients affected by SS has been evaluated. The laser therapy equipment used was the Pointer Pulse, emitting light in the red visible spectrum (650 nm), with a power of 5 mW and an irradiation time of 120 s per acupoint, in an area of 3.14 mm2 (fluence = 19.2 J/cm2, power density = 0.16 W/cm2, total dose = 0.6 J). The following acupuncture points were stimulated bilaterally: LI 2 Erjian, ST 5 Daying, ST 6 Jiache, ST 7 Xiaguan, SI 19 Tinggong, and BL 13 Feishu. True laser acupuncture led to a significantly higher amount of saliva production, measured after the end of the protocol (5 weeks), and during the 6-month follow-up period. The results are stable from the end of the protocol until the 3rd month of follow-up; during the last control, a slight but significant decrease in production has also been shown. This preliminary study proposes laser acupuncture as a possible treatment for improving salivary flow rates in patients with SS, but further validation on a larger sample is still necessary.

Keywords

Laser therapy Acupuncture Salivary flow Sjögren 

Introduction

Sjögren’s syndrome (SS) is a multisystem autoimmune disease characterized by hypofunction of the salivary and lacrimal glands [1]. Its etiopathogenesis remains obscure with a current scenario involving the activation of immune responses upon interaction of environmental and genetic contributors. Treatment of SS is mainly empirical due to the lack of well-controlled studies [2]. Glandular manifestations of SS, salivary and lachrymal, are mostly alleviated with empirical/symptomatic treatments, such as saliva substitutes, eye lubricants, and cholinergic stimulators [2].

Low-level laser therapy (LLLT) is an approach increasingly used in medicine; laser biostimulation can obtain different intracellular biological reactions to stimulate regenerative abilities, without undesired adverse effects, reducing also the pharmacological support and its possible invasiveness [3]. The use of lasers emitting light with a wavelength included within the limits of the optical window, and set with parameters suited to obtain a biostimulating effect, has also been recommended as an effective alternative to metal needles for the stimulation of acupuncture or musculoskeletal trigger points; this form of therapy is termed “laser acupuncture” to distinguish it from the wider therapeutic applications of such laser devices. Laser acupuncture has been promoted as characteristically safer than needle acupuncture due to the non-invasive nature of treatment and as a method that is more appropriate for the stimulation of difficult points [4, 5].

To date, few reports have been published describing the efficacy of acupuncture in treating patients with hyposalivation associated to SS [6, 7, 8, 9] and laser acupuncture has never been reported as a therapeutic option.

The aim of this pilot prospective randomized placebo-controlled study was to estimate the effects and the efficacy of laser acupuncture on salivary flow rates in patients with severe xerostomia due to SS.

Patients and methods

Consecutive Caucasian patients attending the Oral Medicine Section of the CIR–Dental School, University of Turin, Italy, from January 2009 and July 2012, were selected.

The inclusion criteria were: (a) diagnosis of SS on the basis of AECG criteria [10], (b) presence of reported complaint of xerostomia in female patients, and (c) ability to complete the present clinical trial. The exclusion criteria were: (a) previous head and neck radiotherapy, (b) diagnosed lymphoma, (c) hepatitis C infection, and (d) pregnant or breast-feeding women.

Different treatment options were discussed with the patients, and they all submitted written informed consent before enrolment, which was carried out in accordance with the declaration of Helsinki.

Diagnosis of SS was made after assessment by specialists in oral medicine, ophthalmology, and rheumatology.

Saliva flow was measured between 09:00 and 11:00 a.m., and the patients were not allowed to eat, smoke, or brush their teeth 2 h prior to the measurement. Prior to the test, the patients were encouraged to adopt a restful position and told to swallow the saliva. An unstimulated sialometric test using oral Schirmer’s test (WST) was carried out, as described previously [11]. The rate of saliva secretion is expressed as millimeter per 5 min.

The laser therapy equipment used was the Pointer Pulse (GMT2000 s.r.l., Laveno Mombello, Varese, Italy), emitting light in the red visible spectrum (650 nm), and equipped with an audio control trimmer for point detection. The setting parameters were: power of 5 mW and irradiation time of 120 s per acupoint, in an area of 3.14 mm2, (fluence = 19.2 J/cm2, power density = 0.16 W/cm2, total dose = 0.6 J). The use of continuous red radiation, set with the reported parameters, defined the criteria to stimulate efficiently the acupoint. Laser stimulation was repeated weekly over five sessions.

The following acupuncture points were stimulated bilaterally (with this temporal order: left hand, left face, trunk, right face, right hand): LI 2 Erjian, ST 5 Daying, ST 6 Jiache, ST 7 Xiaguan, SI 19 Tinggong, and BL 13 Feishu (Fig. 1).
Fig. 1

The acupuncture points stimulated bilaterally: LI 2 Erjian, ST 5 Daying, ST 6 Jiachè, ST 7 Xiaguan, SI 19 Tinggong, BL 13 Feishù

For the placebo group, the same specific equipment for laser acupuncture was used, which remained on the acupoint for the same period, without emitting any radiation but with the same sound.

Allocation to treatment was performed by non-clinical staff via a permuted random block approach and was concealed in opaque envelopes, which were opened on the first day of laser session (T1).

A single skilled examiner (A. C.) visited patients and performed laser acupuncture. Clinical measurements were performed 1 week before the first laser procedure (T0), after each laser session (T1–T5), and 30 (T6)–90 (T7)–180 (T8) days after.

Describing general information, data was reported as means and standard deviation (SD), unless otherwise described. Differences from baseline preoperative values salivary rates was not normally distributed (Shapiro–Wilk test); Wilcoxon’s signed rank was used to calculate the significance of the outcome data in the same group during the different times of the proposed protocol, whereas Mann–Whitney test was used to calculate the difference between the two groups. P values ≤ 0.05 were considered to be statistically significant. SPSS (SPSS for windows, version 19, SPSS inc, Chicago, IL, USA) statistical software was utilized.

Results

A total of 26 female patients took part in the study; the mean age at presentation was 69.31 years (±9.83). Of the 26 patients with severe xerostomia, 14 were treated with laser acupuncture (group A) and 12 patients received placebo laser acupuncture (group B).

True laser acupuncture led to a significantly higher amount of saliva production, measured immediately after the end of the protocol (T5) and during the follow-up period (T6–T8), statistically greater than the amount produced in the placebo group (Table 1). In Table 2, we provide the description of the saliva level, for each patient, during the different time of the proposed protocol.
Table 1

The comparison of salivary flow rates at before (T0) and after (T5–T8) the proposed protocol with laser acupuncture, in the two groups (group A = laser; group B = placebo)

 

Salivary flow

Rates (mm)

P value

Group A

Group B

T0

5.59 (±4.79)

4.54 (±1.12)

0.705

T5

29.7 (±40.88)

4.59 (±1.93)

0.000

T6

29.04 (±37.98)

4.91 (±1.44)

0.002

T7

28.61 (±36.42)

4.55 (±1.38)

0.004

T8

23.45 (±29.81)

4.54 (±1.69)

0.002

Test statistics: Mann–Whitney test (data with statistical significance expressed in italics)

Table 2

The change of saliva flow, for each treated patient, during the study period (group A = laser; group B = placebo)

  

T0

T1

T5

T6

T7

T8

Patient

Group

#1

A

2.3

26

30

34

25

2.3

#2

A

19

54

58

62

52

19

#3

A

4.5

4.5

2,5

2

2

4.5

#4

A

5

8.5

10

9.1

8

5

#5

A

4.5

6.8

8.2

9.1

7.8

4.5

#6

A

2.5

8.5

8.9

8.6

8.2

2.5

#7

A

0

4

2.5

2

2

0

#8

A

6.6

12.5

13

12

10

6.6

#9

A

7

67

62

60

49

7

#10

A

4.4

7.8

7.8

10.5

11.4

4.4

#11

A

5.5

10.5

11

11

8.1

5.5

#12

A

6

48

47

42

30

6

#14

A

11

152

140

133

110

11

#15

B

0

5.7

5.7

5.2

4.8

0

#16

B

3.5

3.4

3.6

3.4

3

3.5

#17

B

2.5

3

4.5

3.2

2.9

2.5

#18

B

3

1

2.5

2.3

2

3

#19

B

5.4

5.5

5.6

4

4.6

5.4

#20

B

6

5.7

5.5

5.7

5

6

#21

B

5

3.5

4.2

5.6

4

5

#22

B

4

2.7

2.9

3

0

4

#23

B

5.7

4.8

5.3

5.7

5

5.7

#24

B

5.5

6.7

6

5.7

5.3

5.5

#25

B

5.2

7.9

7.7

6.5

6.2

5.2

#26

B

4.2

4.9

5.6

5.5

4.6

4.2

Considering only the test group, saliva production is significantly greater from the end of the protocol until the 6th month of follow-up (Table 3). However, at the end of the follow-up period a slightly but significantly decrease in production has been shown; the results are stable from the end of the protocol until the 3rd month of follow-up.
Table 3

Comparison of unstimulated whole salivary flow (UWS) during the different time of the proposed protocol in the laser acupuncture group

UWS

 

T5 vs T0

T6 vs T0

T7 vs T0

T8 vs T0

Z

−3.180a

−3.234a

−3.171a

−3.170a

P§

0.001

0.001

0.002

0.002

 

T6 vs T5

T7 vs T5

T8 vs T5

 

Z

−0.196b

−0.157b

−2.325b

 

P§

0.844

0.875

0.020

 
 

T7 vs T6

T8 vs T6

T8 vs T7

 

Z

−0.700b

−2.731b

−2.825b

 

P§

0.484

0.006

0.005

 

Test statistics: Wilcoxon Signed Ranks Test (data with statistical significance expressed in italics)

§Asymp. Sig. (two-tailed)

aBased on positive ranks

bBased on negative ranks

Patients did not complain of undesired side effects during the protocol period.

Discussion

Nowadays, treatment of Sjögren’s syndrome patients is challenging, with few effective therapeutic agents being available and often being the cause of severe adverse effects [2].

Xerostomia is a well-known symptom of some systemic diseases as Sjögren’s syndrome, as well as an unwanted side effect of radiation treatment or various medications. It may cause different problems for the affected patients as difficulties in speaking, eating, and swallowing; dental caries and oral infections; failure to wear dentures; altered sense of taste; and can be both socially and physically handicapping [11].

Over the last decade, many non-cancer patients with xerostomia have been treated with traditional acupuncture, reporting an increase in their salivary flow rates, which lasted during a long observation period [6, 9, 11, 12, 13, 14]. A recent systematic review also stated that there is some evidence suggesting that acupuncture could result in a small increase in saliva production in patients with dry mouth following radiotherapy. [15].

Various acupuncture points can be used to treat xerostomia such as auricular points, digital points, or local points on the face [16, 17]. We decided to use the following acupuncture points (LI 2 Erjian, ST 5 Daying, ST 6 Jiache, ST 7 Xiaguan, SI 19 Tinggong, BL 13 Feishu) because of previously reported papers on their benefit for the purpose and because, in the experience of the authors, local points on the face provide a more familiar environment for dentists and are more welcomed by patients [16]. Acupuncture at LI 2, a point commonly used in clinical practice to treat xerostomia, was associated with neuronal activations appearing to be correlated to saliva production [18].

To the best of our knowledge, laser acupuncture has never been used for the treatment of SS patients. We reported that laser acupuncture led to a higher amount of saliva production, measured after the end of the protocol, statistically higher than the amount produced in the placebo group. It seemed that the effectiveness of the treatment had a limited range of action, well lasting for the first 3 months with a beginning of little decrease during the 6th month.

These findings might have a significant clinical impact since LLLT is easy to perform, and does not increase morbidity or presents side effects.

This preliminary study proposes laser acupuncture as a possible treatment for improving salivary flow rates in patients with SS. Future randomized and controlled trials are, however, required to confirm the results of this study as well as the appropriate laser settings, and also assessing other parameters such as dry mouth symptoms, oral infections, and periodontal index.

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Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  • Adriana Cafaro
    • 1
  • Paolo Giacomo Arduino
    • 1
  • Alessio Gambino
    • 1
  • Ercole Romagnoli
    • 2
  • Roberto Broccoletti
    • 1
  1. 1.Department of Surgical Sciences, CIR–Dental SchoolUniversity of TurinTurinItaly
  2. 2.Department of Surgical Sciences and Integrated DiagnosticsGenoa UniversityGenoaItaly

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