INTRODUCTION

A chronic lips’ lymphedema (CLL) is a chronic recurrent disease which is characterized by persistent enlargement of lips due to local disorders of lymph’s flow and microcirculation [1, 2].

Until now all disorders connected with the enlargement of lips were diagnosed as macrochilia. The development of macrochilia and its treatment in many cases depends on topographic and anatomic disposition of lips. Being located on the border of two media (external and internal), lips are constantly exposed to influence of numerous and diverse factors which in complex take part in the development of this disease [1, 2].

Recently, the opinion is gradually being formed about the reasonability to distinguish the separate nosologic forms of macrochilia. The attempts are made to reveal the pathogwscp-inciple of one or another disease form, to determine the peculiarities of clinical symptoms of the basic pathology and an accompanying disease.

The diversity of disease clinical symptoms is defined by different degree of functional and transport deficiency lips’ lymphatic and venous capillaries, which is always developed on the background of different chronic inflammatory processes’ origin in the lips’ tissue (Herpes Simplex, fissural, exfoliative, posttraumatic and postradial chilitises).

The purpose of the present investigation is to study the diagnostic methods and clinical features peculiarities of the lips’ lymphedema among patients with a generalized periodontitis.

MATERIAL AND METHODS

This article is based on the complex examination of 70 patients with a chronic lips’ lymphedema.

The dependence of clinical course of the disease from the very beginning of the disease, the age of a patient and also the connection with other factors as a generalized periodontitis, for example, were analyzed.

To study the pathogenesis of chronic lips’ lymphedema we investigated the proteolytic activity of saliva mixed with reactive oxygen in tissues of 36 patients with a generalized periodontitis and the lips’ lymphedema. Among the examined patients – 12 had a chronic course of periodontitis and 24 had an acute form. The proteolytic activity of mixed saliva was estimated by segregation of protaminsulfate according to the method of Veremeenko K. (1973) [3], and the reactive oxygen in the tissue of affected lip by the method of polarography on the apparatus (PO 2 Rtable).

RESULTS AND DISCUSSION

While carrying out the clinical investigation of patients with the chronic lips’ lymphedema and studying their anamnesis’ data, we paid attention to manifestations of different character in the course of the disease: separate symptoms had no development in conformity with natural laws. Some patients had these symptoms rather clear; others didn’t have them at all. The seriousness of the course of the disease basically was depending on the time of the beginning of the pathological process.

The 70 patients with the chronic lips’ lymphedema diagnosis were examined, 42 of them had a generalized periodontitis, 12 had a chronic course and 24 patients had an acute form of the disease. The degree, the clinical and roentgenologic picture of a generalized periodontitis corresponds to the heaviness and character of the disease course. 79% of patients with an acute form of a generalized periodontitis at the period of the recurrence of the chronic lymphedema of lips had enlarged regional lymphatic nodes not connected together with surrounded tissue and sensitive to palpation. The clinical picture of symptomatic hypertrophic gingivitis had a different degree of heaviness. The patients with a granular form complained of considerable stomatorrhagia, pain and oedematose of gingival. At the time of objective examination the hyperemic oedematose papillae of gingival with strongly expressed cyanosis were found.

The desquamation of epithelium is on the periphery of the papillae. The gingival pockets of different depth are revealed as a result of increased edema of gingival and hyperplasia. The color of gingival is slightly changed, the pain and stomatorrhagia are slight or absent by irritation, when we have a fibrous form of hypertrophic gingivitis. The gingival has a thickened shape of a torus at a base; the papillae are of round form and hyperplastic [2, 4]. We observed the fibrous form of hypertrophic gingivitis only in patients with a chronic lips’ lymphedema after a long and persistant course of the disease.

The enlargement of lips with a limited or spreading form, which affects the surrounding tissue of a face from one side or in symmetry, is the main permanent clinical symptom of the chronic lips’ lymphedema, which is diagnosed during the examination.

As a rule the edema has no clear countours, that’s why clinically it is very difficult to determine the lesions’ borders. The nasolabial folds are smoothed out. The colour of the skin and the red edge of the lips are either not changed or the hyperemia with cyanotic tint appears. Not infrequently the marbled picture on the skin of lips is seen during the recurrence. The consistence of the lips’ tissue is of moderate or expressed homogeneous density, it is painless during the palpation. The skin is gathering in either small or large folds. The “finger-prints” remain on an expressed pastous skin. The mucous membrane of lips and cheeks is edematous and moderately strained, it shines and has an expressed vascular picture, and the prints of teeth create a peculiar shape on it. The excretory ductus of minor salivary glands are dilated in some patients. The excreted secretum on the surface of the mucous membrane creates the picture of “drops of dew”. The seriousness of the course of the disease, basically, was depending on the remoteness of the pathological process. While analysing all the symptoms and factors of the disease manifestations, we marked out three groups of patients. The first group (the transitory form) consisted of the patients with the remoteness of the disease up to 6 months (41 men). The clinical picture of this group was characterized by limited edema developing, as a rule, according to the localization of the chronic inflammation of the lip, rare recurrence and gradual regression of the pathologic process. The second group (a labial form) was made up of the patients with the remoteness of the disease from 6 months up to 1 year (18 men.). The typical symptoms of this group were the enlargement of one or both lips, spreading of edema over the bounds of lips and frequent recurrence of the disease. The third group (the stable form) included cheilitidis with the remoteness of the disease over 1 year (11 men). The clinical symptoms of this group were a permanent recurrence course; the lips were enlarged and wrenched outside. At the time of recurrence the edema was spreading on the adjoining regions of the face.

All the patients passed a complex examination with using clinical, biochemical and functional methods.

The comparison of functional investigations showed that the reactive oxygen is six times higher at the pathologic condition than in controls.

The proteolytic activity of saliva in patients with symptomatic hypertrophic gingivitis with a different degree of heaviness was studied. It is known, that under physiological conditions, there is the equilibrium between systems of the proteolytic enzymes and their inhibitors. The raised activity of enzymes or their releasing into tissues serves as a starting mechanism of development of heavy pathologic processes in the oral cavity [4]. Clear dependence between the activity of proteolytic enzymes and the course of the generalized periondontitis in patients with the chronic lips’ lymphedema was determined. The given data (table I) shows that the indices of the proteolysis are increased in chronic and acute courses of hypertrophic gingivitis. The proteolysis is raised in patients with an acute course of the disease, especially, in the cases with an expressed edema of lips, phenomenon of hyperemia and desquamation of gingival epithelium. Protaminlytic activity of mixed saliva in such patients doubles. In the subsequent investigations it seemed advisable to study the activity of proteolysis after the treatment (table III).

From our point of view the necessary conditions for successful treatment are:

1. A timely diagnosis of the disease with determination of its clinical form and the degree of a generalized periodontitis;

2. The obligatory and maximally thorough removal of the foci of a chronic infection as factors provoking the development of a chronic lips’ lymphedema;

3. The clear differentiation of a conservative therapy methods for every specific clinical form of the chronic lips’ lymphedema with the generalized periodontitis.

The basic tasks of therapeutic tactics were:

• the treatment of a background chronic inflammatory lips’ disease;

• the treatment of a generalized periodontitis and its symptoms;

• the normalization of the microcirculation, the lymph drainage, the vascular.

Permeability, the elimination of acidosis and hypoxia, and also the influence on the processes of hypertrophy, fibrosis and sclerosis.

These directions were realized by a local and general approach to the treatment of the disease. The physicians’ tactics was based on the data of functional investigations, also on the peculiarities of the clinical form of the chronic lips’ lymphedema. The general condition of the patient was obligatory taken into consideration. For this purpose the patients were investigated according to their symptoms in the policlinic by the place of their residence, and, when necessary, the patients were consulted by scientific workers of the faculties of the National Medical University.

The treatment of patients began from the elimination of the foci of chronic infections of oral cavity. The “suspicious” teeth were subjected to X-ray examination. While revealing the chronic periodontitis, cystogranulomas, follicular or radicular cysts, the conservative or surgical treatment was used according to the symptoms of the patients. The teeth, which were not subjected to treatment, were extracted.

If the patients were emotionally unstable, the psychological training was conducted constantly in the time of the sanation and local treatment. A good contact with a patient was provided by creating the atmosphere of goodwill, by explaining the necessity of the sanation of oral cavity for successful results of the treatment of the basic disease.

The compulsary component of the local treatment of all the forms of the chronic lips’ lymphedema with the generalized periodontitis is the hirudotherapy.

The therapeutic effect of the hirudotherapy is concluded in mechanical, reflectoral and biological influence. The secretum of a leech renders a general nonspecific action on the human organism. The evidence of it lies in the increase of a phagocytic activity of neutrophils of blood owing to the influence of components of the secretum of a leech on the system of complement [5].

The course of treatment consists of 5 seances up of two leeches on the area of the lips’ edema and a hypertrophic site of the gingiva every second day.

With the purpose of suppression of the saliva proteolytic activity, which in such patients can promote: to the maintenance of edema, the rising of the permeability of capillary system of lips and to a nonspicific stimulation of biochemical processes such as: the increasing of the level of tissue respiration; the intensification of oxidation-reduction reaction; the lowering of the hyaluronidase activity, which leads to the diminution of capillary fragility), we used the enzyme Gordox, which is an inhibitor of kallikrein and other proteinases in plasma, in blood cells and tissues [4, 6]. The evidence for using of this ferment is high concentration of proteinases in tissues. The Gordox was used locally in the form of phonophoresis on the gingiva, the course of treatment is 10 seances.

The essential task of a local treatment was: the normalization of microcirculation, the lymph drainage, the drainage function of lymph lips’ vessels; the restoration of vascular permeability in patients with the chronic lymphedema of lips; and, &\m the influence on the processes of hypertrophy and fibrosis and the prevention of their further development.

For this purpose all the patients were prescribed the preparation Lymphomyosot. The pharmacologic action of this preparation depends on the properties of the number of vegetable and mineral components entering in its structure [7]. It was prescribed 10 drops three times per day, before meals, over a long period of time, up to three months.

Besides, Echinacea compositum S was prescribed. This complex antihomotoxic preparation, thanks to its universality, renders immunomodulating, antimicrobial, disintoxicating and antiinflammatory action. The activity of preparation is determined by the properties and combination of 26 medicamentous components entering in its structure [7]. This preparation was prescribed intramuscularly twice a week. The general duration of the course of treatment was 30-45 days.

The general treatment of the given patients also included hyposensibilization preparations, Ascorutin and polyvitaminic complexes.

THE RESULTS OF TREATMENT

The highest therapeutic effect was observed in the patients with the transitory and labile forms of the chronic lips’ lymphedema with the first and second degree of the generalized periodontitis. A prolonged remission was achieved in the patients with the stable form of the chronic lips’ lymphedema and the fibrous hypertrophic gingivitis.

CONCLUSIONS

The analysis of the data testifies the direct dependence of the heaviness of the course of the labile and stable forms of the chronic lips’ lymphedema and the expressiveness of a generalized periodontitis.

The effectiveness of the proposed treatment allowed to increase considerably the recovery of the patients and to lower the recurrences of the disease.

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LITERATURE

1.     Коваль Н.И.: Хроническая лимфєдема губ. Клиника. Диагностика. Лечение. Автореф.дис…канд.мед.наук 1989, 25c.

2.     Коваль Н.И.: Хроническая лимфєдема губ. Клиника. Диагностика. Лечение. Монография, Киев, 2007. 94c.

3.     Веремеенко К.Н., Хоменко ЛА.: Протеолитическая активность слюны у больных пародонтитом. Стоматология 1973, № 3, C. 72-73.

4.     Вороніна І.Є.: Порушення мінерального обміну в альвеолярної кістці при генералізованому пародонтиті та їх корекція у хворих на цукровий діабет. Автореф.канд.дис. К. 2003, C. 18.

5.     Борисенко А.В., Несін А.Ф., Коваль Н.І.: Використання гирудотерапії у комплексному лікуванні стоматологічних захворювань. Науковий Вісник НМУ ім. О.О.Богомольця, 2006, C. 126-130.

6.     Коваль Н.И., Воронина И.Е.: Применение препарата Энелбин-100 ретард в комплексном лечении больных хронической лимфэдемой губ. Современная стоматология 2006, №2, C. 28-30.

7.     Комплексные антигомотоксические препараты. Справочник Heel 2002, C. 65-67, 104-107.

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Pracę nadesłano: 21.01.2011 r.
Przyjęto do druku: 09.03.2011 r.