Part of Photomedicine and Laser Surgery
Volume 24, Number 5, 2006
Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil.
CO2 Laser Cryptolysis by Coagulation for the Treatment of Halitosis
THERE ARE MANY CAUSES of halitosis, but most of them are
related to the oral cavity (90%); others are related to otolaryngology
and respiratory diseases (8%). Gastrointestinal
diseases, liver/renal impairment, and other metabolic syndromes
are minor causes (2%).
Halitosis is primarily related to the decomposition of organic
material by anaerobic proteolytic bacteria, consequently
increasing the production of odorivectors such as volatile sulphur
compounds (VSC) exhaled during breathing.
Hydrogen sulfide, methylmercaptans, and dimethylsulfide
are the VSC most responsible for breath malodor and they are
easily perceived by human sense of smell.6–8 There are other
odorivectors (such as cadaverine, putrescine, and scatol) that
are much less offensive to the human sense of smell than
VSC.
Recently, methods and instruments have been developed to
identify and quantify substances present in the breathed air.
The Halimeter® is a device with an electrochemical voltammeter
sensor that generates a signal when exposed to VSC sulphur
compounds. It has a digital display that records the quantity of
VSC in parts per billion (ppb) present in the expired air. Results
below 150 ppb are considered normal. The Halimeter®
is one of the most common devices used that allows a correct
diagnosis, follow-up, and reassessment of halitosis.
Palatine tonsils contain crypts (Fig. 1), which are twisted tubular
invaginations extending from the tonsillar surface and
penetrating deeply through the parenchyma. These crypts,
depending on the depth, may retain exfoliated epithelium cells,
keratin debris, and foreign particles, causing the accumulation
of secretion and caseum formation. Therefore, palatine tonsils
are the most suitable sites for the activity of anaerobic bacteria
in the upper airway system.
Chronic caseous tonsillitis (CCT) is a common disease at
ear, nose, and throat (ENT) clinics, and complaints of halitosis
among patients with CCT are prevalent (about 77%). This
complaint can be very disabling for the patient. Caseum formation
and its retention inside the tonsil crypts characterize CCT.
Caseum retention also may cause inflammation, leading to hyperemia
and hypertophy of the tonsils (Fig. 2). Other CCTrelated
symptoms are throat irritation and sensation of foreign
bodies. CCT affects both men and women at any age, in all
kinds of tonsils, without any relation to their size, and can
occur on one or both sides. Clinically, tonsil caseum is
strongly related to halitosis complaint. However, an objective
measure of halitosis (VSC halitometry) in patients with
CCT has not been described previously in the literature.
The initial approach for CCT includes the use of topical antiseptics,
anti-inflamatories, and oral antibiotics. When this clinical
clinical treatment does not bring relief, surgical excision of the
tonsils is indicated.
Recently, a less invasive therapy has been proposed for CCT
treatment in order to preserve the tonsils due to their importance
in local immunological process. This therapy is CO2
laser cryptolysis by coagulation (LCC). LCC is tolerated quite
well by patients and is virtually painless. The treatment takes
four to six sessions on average, with an interval of 4 weeks between
laser sessions. The coagulation is obtained with moderate
CO2 laser power density, reaching temperatures in the
tonsillary tissue of 50–100°C. Consequently, there is dehydration,
whitening, and contraction of the tissue due to protein and
collagen denaturation. With this technique, which is more
conservative than conventional ones using the CO2 laser, the
laser/tissue interaction occurs only superficially in the epithelial
layer, widening the tonsillar ostium, reducing crypt depth,
and decreasing caseum retention.
Recent studies have shown that patients with CCT treated by
CO2 LCC reported a considerable clinical improvement of halitosis.
However, a systematic and objective study using the
VSC halitometry in these patients has not yet been described.
The study of halitosis in these patients is justified since it is a
very common symptom among these patients, and CO2 LCC is
a relatively new technique.
The aim of this study is to evaluate the impact of CO2 LCC
on the VSC halitometry profile of patients with CCT and complaints
of halitosis.
METHODS
Study design
Thirty-eight adult patients of both genders, with CCT diagnosis
and halitosis complaint, were selected at the Medicine
Laser Unit of the University Hospital Center. These patients
were evaluated by a multiprofessional team that included a senior
otolaryngologist, a specialist in internal medicine, and a
senior dentist.
Selection criteria
All patients were assessed at the ENT outpatient clinic at
the State University of Campinas (UNICAMP). They underwent
anamnesis and complete clinical/oral examinations, and
answered questions related to food habits, oral hygiene, medical
history, and use of medications. After failure with conventional
clinical treatment for CCT, they were selected for CO2
LCC.
The exclusion criteria were patients with prothesis or
restorations not well adapted, presence of periodontal diseases,
tooth decay, exposed tooth pulps, presence of infection of the
soft tissue of the oral cavity, presence of systemic diseases
(such as gastrointestinal, pulmonary, hepatic, endocrine, autoimmune,
or other metabolic disorders), and pregnancy. Smokers,
heavy alcoholic drinkers (more than 30 g of alcohol/day),
drug users, those taking any kind of regular medication, and
those with xerostomia were also excluded. Except for the CCT,
all patients had a normal medical history. These criteria were
established to exclude other causes of halitosis.
The patients underwent four CO2 LCC sessions with an interval
of 4 weeks between the sessions. At each session, all patients
were reassessed concerning symptom improvement.
The VSC halitometry test was performed immediately before
each laser session. The halitometry values were recorded
for statistical analysis.
Halitometry technique
Preparation. All patients received instructions before the
halitometry to abstain from oral mouthwash or toothpaste,
from chewing gum, and from spicy or seasoned food at least
three h before halitometry, and to not fast for a period of more
than four h.
All patients agreed to participate in the study in accordance
with the University Ethical Research Committee and signed an
informed consent agreement.
Technique. Halitometry was always performed in the same
time period, at the beginning of the afternoon, on Monday, at
the Multidisciplinary Group of Laser Medicine at State University
of Campinas Hospital. The VSC halitometry technique
(Fig. 3) followed the instruction manual for the Halimeter®
(Halimeter RH-17 Series, Interscan Corp., Chatsworth, CA).
Device. The Halimeter® device measures VSC in ppb, and
before each measurement it is set to 0 ppb according to manufacturer’s
instructions. The technique consisted of having the patient
keeping his/her mouth closed for 3 min prior to testing, trimming
the Halimeter® to zero, inserting a sterile straw probe 2 inches into
a slightly opened mouth (the straw must not touch the lips, teeth,
or internal surface of the mouth, nor could the patient blow
through or inhale from the straw) and holding one’s breath for the
few seconds of testing, until a peak value is obtained which will
occur in 8–10 sec on average. The display reading was allowed to
return to 10 ppb before the next measurement was taken. This
procedure was repeated three times, and the results were recorded.
Laser cryptolisys technique
The CO2 laser used in this study was Sharplan 40C with
nominal power of 40 W (CO2 Surgical Lasers System, Sharplan
Lasers, Inc., Israel) attached to an articulated arm, handpiece,
and a scanner accessory (Swiftlase). A smoke aspirator
with biological filter, frontal light beam to illuminate the
orophaynx, and protection glasses for the patient and medical
team were also used. The coagulation technique with CO2
laser,15 consisted of applications of 6 W of continuous wave
(CW) laser power, in scanned and unfocused mode, over a
mean area of 2.2 mm2, initially only around the crypts and following
the shape of their openings (Fig. 4). The laser fluence
applied around the crypt was about 54.5 joules/cm2. At a subsequent
time, the laser beam was swept over the entire tonsillar
surface with a fluence of about 18 joules/cm2 (Fig. 5). It is important
that the handpiece not touch the tonsils and be lined up
with the labial commissura. This procedure was repeated every
4 weeks, 4 sessions in total for each patient.
To calculate the laser fluence applied around the crypt, the
sweeping speed was estimated to be 5 mm/sec, the laser beam
diameter 2.2 mm, and a laser power of 6 W, resulting in a energy
density, or fluence, of 54.5 joules/cm2. The laser was
swept over the tonsilar surface at an estimated speed of 15
mm/sec, resulting in a fluence of about 18 joules/cm2.
The patients were advised not to eat spices, seasonings, or
acidic food, and to avoid hard or crisp food during the 2 first
days after the procedure.
Data treatment
An electronic data sheet was created using Microsoft Windows
Excel® software with name, registration number, age,
gender, the three halitometry values (in ppb of VSC), and the
mean of the three measurements (in ppb of VSC).
Statistical analysis
The mean of the three halitometry values of each patient obtained
before each laser session was used for the statistical
analysis. Non-parametric tests were used because the population
was considered to have a distribution different from normal.
The different halitometry measures were compared within
the same group and between the two groups. The Friedman test
was used for the intra-group comparison to analyze the halitometry
profile in a population throughout treatment.
Comparisons between the groups were made using the
Mann-Whitney test. Percentual variation (PV) between the
second, third, and fourth laser sessions, in relation to initial
halitometry, was calculated in both groups.
The PV formula was as follows:
PV = 100 x (halitometryi - halitometry1)/(halitometry1)
where i = 2, 3, or 4, indicating the halitometry value of the second,
third, and fourth laser sessions, and halitometry1 = initial
halitometry value. Rejection level (p) was fixed at a value of
<=0.05.
* * * *
CONCLUSION
In a selected group of patients with CCT and halitosis complaint,
a new conservative method of CO2 LCC was performed
in order to avoid tonsillectomy. This treatment was well tolerated,
and no side effects were noted. All patients experienced
an improvement of halitosis and other CCT-related symptoms.
In the group of patients presenting an abnormal halitometry
profile, this improvement was approximately 30.1%. All patients
presented normal halitometry after four sessions of CO2
LCC.
Finally, an increase of self-esteem was noticed in both
groups, with improvement in their appearance. Patients also
claimed improvement in their personal relationships with partners,
parents, and friends. Overall, quality of life improved for
patients with CCT and halitosis complaint after undergoing
CO2 LCC treatment. The objective measures of halitometry allowed
patients to monitor their own improvement in halitosis
throughout the CO2 LCC treatment, which increased their selfconfidence.
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