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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 65-69

Hirudotherapy in dentistry


Department of Oral Medicine and Radiology, AECS Maaruti College of Dental Sciences and Research, Bengaluru, Karnataka, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Isha Thakur
Department of Oral Medicine and Radiology, AECS Maaruti College of Dental Sciences and Research, Bengaluru - 560 076, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.199987

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  Abstract 

Medicinal leeches have been used in medical and dental specialties over the past many years. Leeches have the property of bloodletting that makes them be used as a therapeutic modality. Leech therapy, also known as hirudotherapy, involves the application of medicinal leeches onto an affected area. Leeches suck the blood with an initial painless bite. Saliva of leech has many biologically active substances that make the therapy useful and unique. Hirudotherapy is used in many medical and dental disease conditions despite many complications arising from it. This article gives a brief review of hirudotherapy, its application in dental disease conditions, and its complications.

Keywords: Bioactive substances, hirudotherapy, leeches, saliva


How to cite this article:
Thakur I, Satheesha Reddy B H, Patil S, Rajendra K. Hirudotherapy in dentistry. Int J Oral Health Sci 2016;6:65-9

How to cite this URL:
Thakur I, Satheesha Reddy B H, Patil S, Rajendra K. Hirudotherapy in dentistry. Int J Oral Health Sci [serial online] 2016 [cited 2017 Mar 28];6:65-9. Available from: http://www.ijohsjournal.org/text.asp?2016/6/2/65/199987


  Introduction Top


Leeches when used in treatment of certain diseases, the therapy is termed as hirudotherapy – a Latin word. Leech is derived from an English word, laece. Hirudotherapy is done with the assistance of medicinal leeches only [Figure 1] and the wild type is not used. These medicinal leeches (annelids) possess a unique ability to suck out blood that is pooled in various tissues. They use their proboscis [Figure 2] to puncture the skin of the host with its three curved jaws in a Y-shaped cut, simultaneously producing an anesthetic agent along with saliva. This is the reason for the painless bite of leeches.[1] A single blood meal may take weeks or months to digest; thus, a leech may need only one or two blood meals a year. These medicinal leeches produce many other biologically active substances, mainly hirudin that acts in different ways on the host tissues that is discussed later in the article.[2],[3]
Figure 1: Medicinal leech

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Figure 2: Parts of leech

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  History Top


The practice of bloodletting has been in existence for the past 3000 years. It was first started in Egypt, then followed by Greeks, Romans, Arabs, and Asians and then spread throughout Europe.[4] In Greece, use of leeches for medicinal purpose was first described by Themison.[5] In Sanskrit writings also, leech therapy has been mentioned as being used on mouth, lips, or other small areas with the help of tubes. Bloodletting in a generalized method was done by venesection and arteriotomy and in a localized method was done by scarification with cupping and leeches. Venesection was the most common procedure at that time utilizing the median cubital vein. However, many different veins could also be used. The main instruments for this technique were lancets and fleams. Thumb lancets were small, sharp-pointed, two-edged instruments often with an ivory or tortoise shell case that the physician could carry in his/her pocket. Fleams were usually devices with multiple, variably sized blades that folded into a case-like a pocketknife.[4] In dentistry, Thomas Bell was the first one to use six leeches in an oroantral fistula in a patient with facial swelling in 1817.[6] Harris introduced application of leeches for the gingival abscess drainage in 1839.[6]


  Medicinal Leeches Top


Leech is a parasite but has been used as a therapeutic agent over the past thousand years. They grow well in temperate climates and in muddy-weeded freshwaters. All leeches cannot be used as therapeutic agents, the species that are used for treating the diseased conditions are known as medicinal leeches. Medicinal leeches belong to the order Arhynchobdellida, family Hirundinidae.[7] Medicinal leeches mainly feed on blood so-called as hemophagic whereas other leeches eat other small invertebrates and some feed on decomposed bodies. Medicinal leeches also have smaller anterior sucker as compared to other types. These features of medicinal leeches along with their biologically active agents [Table 1] make them different from other types of leeches.[4]
Table 1: Leech saliva contents and their actions

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The most commonly used medicinal leech is known as Hirudo medicinalis/European Medical Leech.[14] Other Hirudo species less commonly used as medicinal leeches are Helleborus orientalis, Hirudo troctina, Hirudo verbana, Hirudinaria manillensis, or Hirudinaria granulosa, the Asian Medical Leech. Besides these, Macrobdella decora or the North American Medical Leech is also used.[1]


  Mode of Mechanism of Leeches Top


Leeches have various proteins in their saliva which are produced once they bite the host tissue.[15] These substances are basically responsible for the actions of leeches as therapeutic agents.[16] They block the blood coagulation by secreting an anticoagulant from saliva called as “hirudin” which acts on various steps of coagulation cascade and also acts as anti-platelet agent.[5],[17] Leeches are applied in an area (skin or intraoral) with the help of glass containers or tubes and a sterile gauze to block the path of leech during sucking.[18] Leech therapy involves an initial bite, which is usually painless (leech saliva contains a mild anesthetic), and has an attachment period lasting 20–45 min, during which the leech sucks between 5 and 15 ml of blood. Its main therapeutic benefits are not derived from the blood removed during the biting (although this may provide dramatic relief at first), but from the anticoagulant and vasodilator contained in the leech saliva. These properties permit the wound to ooze up to 50 ml of blood for up to 48 h. Leech bites usually bleed for an average of 6 h.[19],[20] The area should be cleaned with distilled water after every 3–4 h. After the procedure, ecchymosis will be seen on the target tissue that will disappear within 2–3 weeks.[21]

The chronicity of the disease will decide the number of series required to treat a particular disease. Three to eight treatments (in one series) at an interval of 2/3/4/even 6 days are required and the series should not be administered more than 3 times a year. For the effectiveness of the treatment, patient has to complete the treatment according to the required number and duration of the sessions.[22]


  Indications of Hirudotherapy in Dentistry Top


Smeets and Engelberts in 1995 reported a case of severe macroglossia causing respiratory distress, following intraoral surgery. Leeches were used to reduce this life-threatening swelling of the tongue as usual methods were found inadequate. Leeches can be used for the drainage of abscesses. Leeches can be used in the management of periodontitis, gingivitis, and inflammation of the periosteum as they have anti-inflammatory, immunostimulant, and analgesic effects. Leeches also have antibacterial agents that can inhibit the bacterial growth in the oral cavity.[23]

Anticoagulants present in leech's saliva increase the blood flow and nutrients to the gums.[22] In this treatment procedure, leeches are placed on the gingiva for about 10–15 min with a special application set that is suitable for application on oral mucosa. About 3–5 leeches in mild cases and 5–7 in severe cases of periodontal disorders are used. In cases of chronic generalized periodontitis, use of medicinal leeches followed by application of biosoluble “Piyavit” gel based on extract of H. medicinalis showed local analgesic and anti-inflammatory effect.[23] Piyavit contains medicinal leech saliva as the main source of biologically active substances that inhibit platelet-vascular and plasmic hemostasis and provide thrombolysis. It is a novel pharmacological preparation allowed in Russia as an oral antithrombotic drug for clinical use.[24]

Leeches have anticoagulant agents that can be used in hematomas, flap surgeries, and postoperative thrombosis.[16] Hirudotherapy has been proven beneficial in Melkersson–Rosenthal syndrome cases using 2–3 specimens should be applied for 10–15 min on swelling area of lips, oral mucosa, and tongue daily for 4–5 days. In reducing the epithelialization period of oral ulcers, 1–2 leeches on the perifocal areas of the oral ulcers for 7–10 days along with the conventional medication can be used.[22] Leeches can also be used in advanced cases of oral lichen planus.[23] Abal'masov et al. have reported that hirudotherapy is beneficial in the treatment of sialadenosis and sialadenitis cases, more pronounced effects in sialadenosis. However, it is ineffective in chronic parenchymal parotitis with Sjogren's syndrome treatment.[25]

Diabetes mellitus, venous congestion, osteoarthritis pain, cancer, vascular disorders are the other indications where hirudotherapy can be used.

Leech bite is ineffective if the skin is cold and perfumed, in older patients and the smokers.[21]


  Contraindications of Hirudotherapy Top


Anemia, in extreme ages, i.e., in children and old age, weak patients, allergic patients, and bacterial infections, in extreme hot or cold climate, in various blood disorders such as hemophilia and thrombocytopenia, in blood-borne infections such as HIV and hepatitis, are the contraindications to hirudotherapy.[12],[16]


  Complications Top


Complications of leech therapy can be prolonged bleeding, allergic and bacterial reactions, risk of pneumonia, septicemia, gastroenteritis, blister formation and ulcerative necrosis, infection transmission.[17],[26] These complications can be avoided by practicing the below mentioned criteria before, during, and after the procedure.

Before prescribing hirudotherapy, the congested tissue must be examined to ensure that venous congestion is present and not the arterial insufficiency. Medicines that increase the risk of bleeding or reduce immune response should be considered and reviewed. Smoking is contraindicated during therapy because of the vasoconstrictive effects of carbon monoxide and nicotine. Patients must avoid caffeine until therapy is completed to reduce the risk of vasoconstriction. Before the therapy starts, a blood transfusion protocol should also be in place. Prophylactic antibiotic therapy with third-generation cephalosporins has been recommended. Aminoglycosides and quinolones are considered as an alternative as third-generation cephalosporins are capable of developing resistance.[27] The area should be made sterile for the procedure to prevent infective complications. A nontoothed forceps should be used to extract single leech. After therapy, bleeding for 10 h will continue. Hence, area should be cleaned regularly to remove the clots. The vitals should be kept under regular check. Complete blood count should be done daily and area must be kept under regular observation for any tissue color and appearance changes.[28]


  Conclusion Top


Hirudotherapy is one of the oldest naturopathies and is used to treat many diseases. It is relatively inexpensive and indispensable. Leech therapy is used in practice in western part of the world, especially in European countries. In India, it is practiced at many centers in various cities such as Pune, Nashik, Shimoga, and Delhi as Raktamokshana therapy or leech therapy. Leeches are used successfully for various conditions as discussed above, notably in the field of reconstructive or microsurgery, to salvage tissue flaps and skin grafts whose viability is threatened by venous congestion. As the treatment is also associated with various complications, optimal care should be taken while applying the leeches. Researches are still under progress to explore its further uses in dentistry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singh AP. Medicinal leech therapy (hirudotherapy): a brief overview. Complement Ther Clin Pract 2010;16:213-5.  Back to cited text no. 1
    
2.
Davis A, Appel T. Bloodletting Instruments in the National Museum of History and Technology. Washington, D.C.: Smithsonian Institution Press; 1979. p. 34-6.  Back to cited text no. 2
    
3.
Irish JC, Gullane PJ, Mulholland S, Neligan PC. Medicinal leech in head and neck reconstruction. J Otolaryngol 2000;29:327-32.  Back to cited text no. 3
    
4.
Greenstone G. The history of bloodletting. B C Med J 2010;52:12-4.  Back to cited text no. 4
    
5.
Hyson JM. Leech therapy: a history. J Hist Dent 2005;53:25-7.  Back to cited text no. 5
    
6.
Harris CA. The Principles and Practice of Dental Surgery. Philadelphia: Lindsay and Blakiston; 1845. p. 466.  Back to cited text no. 6
    
7.
Sobczak N, Kantyka M. Hirudotherapy in veterinary medicine. Ann Parasitol 2014;60:89-92.  Back to cited text no. 7
    
8.
Abdelgabar AM, Bhowmick BK. The return of the leech. Int J Clin Pract 2003;57:103-5.  Back to cited text no. 8
    
9.
Eldor A, Orevi M, Rigbi M. The role of the leech in medical therapeutics. Blood Rev 1996;10:201-9.  Back to cited text no. 9
    
10.
Abdullah S, Dar LM, Rashid A, Tewari A. Hirudotherapy/leech therapy: Applications and indications in surgery. Arch Clin Exp Surg 2012;1:172-80.  Back to cited text no. 10
    
11.
Sawyer RT. Leech Biology and Behavior: Volume II: Feeding Biology, Ecology, and Systematics. USA: Oxford Science Publications; 1986.  Back to cited text no. 11
    
12.
Glyova O. Modern Hirudotherapy — A Review. (Biotherapeutics, Education and Research Foundation). The (BeTER) LeTTER 2005;2:1-3.  Back to cited text no. 12
    
13.
Godfrey K. Uses of leeches and leech saliva in clinical practice. Nurs Times 1997;93:62-3.  Back to cited text no. 13
    
14.
Haycox CL, Odland PB, Coltrera MD, Raugi GJ. Indications and complications of medicinal leech therapy. J Am Acad Dermatol 1995;33:1053-5.  Back to cited text no. 14
    
15.
Fields WS. The history of leeching and hirudin. Haemostasis 1991;21 Suppl 1:3-10.  Back to cited text no. 15
    
16.
Srivastava A, Sharma R. A brief review on applications of leech therapy. Scholars research library. Arch Appl Sci Res 2010;2:271-4.  Back to cited text no. 16
    
17.
Salzet M. Anticoagulants and inhibitors of platelet aggregation derived from leeches. FEBS Lett 2001;492:187-92.  Back to cited text no. 17
    
18.
Grassberger M, Sherman RA, Gileva OS, Kim CMH, Mumcuoglu KY. Biotherapy-History, Principles and Practice. A Practical Guide to the Diagnosis and Treatment of Disease Using Living Organisms. Springer Netherlands:Springer Science and Business Media; 2013. p. 44.  Back to cited text no. 18
    
19.
Ikizceli I, Avsarogullari L, Sözüer E, Yürümez Y, Akdur O. Bleeding due to a medicinal leech bite. Emerg Med J 2005;22:458-60.  Back to cited text no. 19
    
20.
Kowalczyk T. A low-tech approach to venous congestion. RN 2002;65:26-30.  Back to cited text no. 20
    
21.
Das BK. An overview on Hirudotherapy/leech therapy. Indian Res J Pharm Sci 2014;1:34.  Back to cited text no. 21
    
22.
Rahul S, Swarnasmita P, Janhavi D, Bhuvan J, Shobhit P. Hirudotherapy – A holistic natural healer: A review. IJOCR 2014;2:59-69.  Back to cited text no. 22
    
23.
Smeets IM, Engelberts I. The use of leeches in a case of post-operative life-threatening macroglossia. J Laryngol Otol 1995;109:442-4.  Back to cited text no. 23
    
24.
Baskova IP, Korostelev AN, Chirkova LD, Zavalova LL, Basanova AV, Doutremepuich C. Piyavit from the medicinal leech is a new orally active anticoagulating and antithrombotic drug. Clin Appl Thromb Hemost. 1997;3:40-5.  Back to cited text no. 24
    
25.
Abal'masov DV, Afanas'ev VV, Pozharitskaia MM. Leeching in the treatment of chronic inflammatory and dystrophic diseases of the salivary glands. Stomatologiia (Mosk) 2003;82:43-6.  Back to cited text no. 25
    
26.
Wells MD, Manktelow RT, Boyd JB, Bowen V. The medical leech: an old treatment revisited. Microsurgery 1993;14:183-6.  Back to cited text no. 26
    
27.
Nonomura H, Kato N, Ohno Y, Itokazu M, Matsunaga T, Watanabe K. Indigenous bacterial flora of medicinal leeches and their susceptibilities to 15 antimicrobial agents. J Med Microbiol 1996;45:490-3.   Back to cited text no. 27
    
28.
Marsden BM, Annie N. Hirudotherapy: A guide to using leeches to drain blood from tissue. Clin Pharm 2014;6:69.  Back to cited text no. 28
    


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  In this article
   Abstract
  Introduction
  History
  Medicinal Leeches
   Mode of Mechanis...
   Indications of H...
   Contraindication...
  Complications
  Conclusion
   References
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