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March 12, 2009

By Michael K. Koceja, DDS

Introduction

Dental clinicians often encounter small lesions on the lips and areas bordering the lips that raise an important question: How far outside the oral cavity does the scope of dentistry extend? Where does the practice of dentistry coincide with the overall health of the patient in areas surrounding the oral cavity?

While a dentist should be properly trained and proficient in recognizing the potential serious lesions that can occur on the face and neck, most dentists do not feel comfortable removing more benign lesions on the lips, vermilion border, or areas of the face bordering the oral cavity. This fear is compounded by the use of scalpels or instruments that generate and rely on heat (electrosurge, bipolar devices) to remove these lesions. These instruments can create excessive bleeding, swelling, requisite suturing, and possible residual scarring to highly visible areas surrounding the oral cavity.

Because of these fears and conditions, it would be beneficial to clinician and patient alike if there were a highly predictable method to remove small lesions in the perioral regions with minimal bleeding, along with eliminating the need for sutures and no residual scarring. This would open a potential area of treatment that may have been neglected due to lack of referral or fear of unknown cosmetic results.

In recent months, the Er,Cr:YSGG laser device, which has been primarily used for both hard (1,2) and soft tissue (3) in dental cases, has also been granted clearance by the U.S. Food and Drug Administration for use in dermatological applications (4,5), which can expand its utility in a dental practice. This device represents an atraumatic, scalpel-less methodology for simple perioral lesions and other minor dermatological applications.

This article will present two clinical cases in which an Er,Cr:YSGG laser was used successfully to remove lesions surrounding the oral cavity. The first case involved removal of a mucocele located on the lower lip. The second case was the removal of a small nevus on the vermilion border of the lower lip. Both cases were accomplished with minimal bleeding, no placement of sutures, minimal postoperative discomfort, and no residual scarring. Both cases were submitted for biopsy. As a side note, the importance of biopsy in benign-appearing lesions can't be stressed enough as we never can confidently identify lesions by clinical appearance alone.

Case 1 — Removal of a mucocele

A 9-year-old female presented with a round raised lesion measuring 3 to 4 mm in diameter. It was located on the midleft lower lip. The lesion appeared to be filled with fluid but attempts at drainage were unsuccessful. The patient's mother related a history of the lesion varying in size and stated it had been present for approximately four months (Fig. 1).

Fig. 1: Preop

Clinical diagnosis: Mucocele (inflamed) fluid-filled minor salivary gland.

Er,Cr:YSGG laser treatment recommendations: Incise complete minor salivary gland with Er,Cr:YSGG laser (Waterlase®, Biolase®, Irvine, Calif.) utilizing topical anesthetic. The laser's settings were 1.0 watts, 30 Hz, 9% water, and 12% air.

Procedure: We first performed a circumferential incision and separated the lesion from the surrounding tissue to the base of the duct (Fig. 2). Note that no sutures were necessary. The laser setting was changed to 0.5 watt, 30 Hz, no water, and no air to create a "laser bandage" over the surgical site. Vitamin E gel was then placed over the site to stimulate healing.

Fig. 2: Immediate postop

Pathology report: Microscopic description: A fragment of oral mucosa was remarkable for focal parakeratosis and a rare lymphocyte within the epithelium. No dysplasia was identified. No salivary gland was identified. A PAS-D stain was negative for fungal organisms. Within this area, which is scanty, and at the edge of the biopsy, there were a few neutrophils.

Pathologic diagnosis: Left lower lip, biopsy: oral mucosa with changes suggestive of mucocele. Mild parakeratosis consistent with irritation.

Postoperative treatment and instructions: Placement of vitamin E gel three to four times daily over site. Also prescribed over-the-counter analgesics as needed for discomfort.

We contacted the patient's mother the night of the treatment; she reported no adverse symptoms and minimal discomfort. Patient was seen at one-week follow-up appointment (Fig. 3).

Fig. 3: One week postop

Case 2 — Removal of small nevus

A 36-year-old male presented with a round, raised lesion on the vermilion border of the lower right lip. The lesion measured 3 to 4 mm in diameter. The patient was not sure how or when the lesion appeared. His chief complaint was that he periodically cut into the lesion while shaving, resulting in pain and irritation. The patient had undergone a medical consultation and was told by the practitioner that the lesion could be removed with a scalpel, requiring an elliptical shaped incision to remove the lesion and then placement of sutures to close the wound site. The patient declined treatment due to the high likelihood of scarring to a very visible area of the face (Fig. 4).

Fig. 4: Preop

Clinical diagnosis: Nevus

Laser treatment: Remove the nevus lesion with an Er,Cr:YSGG (2780nm) all-tissue laser.

Laser settings: 1.25 watts, 30 Hz, 9% water, 12% air with .50cc 2% lidocaine, local infiltration, 1-100,000 epinephrine. Used Er,Cr:YSGG laser to circumferentially incise and remove the lesion. No sutures were necessary (Fig. 5). The laser's settings were then changed to 0.5 watt, 30 Hz, no water, and no air. This setting allows for a "laser bandage." Note that the "bandage" setting helps promote hemostasis and healing. Vitamin E gel was then placed over the surgical site.

Fig. 5: Immediate postop

Pathology report: Microscopic description: Sections showed portions of hypertrophic skin with a vaguely papillomatous surface. There was hypergranulosis and hyperkeratosis with mounds of parakeratosis extending off of the papillary tips. There was no dysplasia or invasive component. Focally, the cells showed apparent viropathic effect, consistent with a verruca vulgaris. There was solar elastosis in the underlying dermis with scattered thin-walled vessels. A distinctive area of fibrosis was not appreciated.

Pathologic diagnosis of skin biopsy: Benign keratosis consistent with verruca vulgaris.

Postoperative instructions: Patient was instructed to place vitamin E gel over surgical area three to four times daily, and use over-the-counter analgesics as needed. We contacted the patient the evening of the treatment and he reported no complications and no need for analgesics. The patient was recalled for a two-week postoperative appointment (because he was unable to return for a one-week checkup) (Fig. 6).

Fig. 6: Two weeks postop

Conclusion

Both cases demonstrate the effectiveness of using an Er,Cr:YSGG all-tissue dental laser to safely and atraumatically remove small, benign lesions from the facial areas bordering the oral cavity. The laser causes minimal bleeding, minimal discomfort, and very little possibility of scarring.

As dentists, we are the health-care professionals most likely to encounter and diagnose these lesions. At that point, we can remove or make the decision to refer out to a specialist. However, with a device like the Er,Cr:YSGG laser available, dentists can choose to retain more of these simple soft-tissue procedures.

As stated previously, if you do choose to remove any oral lesions, biopsy is a mandatory step in the process. This demonstrates to your patients that you can help provide meaningful information and care to their whole body and health — especially in the vital area of face and neck.

Michael K. Koceja, DDS, graduated from Marquette University School of Dentistry in 1986. He then served for eight years in the United States Navy, undergoing extensive training in all areas of dentistry, including a one-year periodontal fellowship. Upon his departure from the Navy, he set up a successful practice in San Marcos, Calif. Dr. Koceja has been actively involved in the use of lasers in dentistry since 1999. He has lectured extensively on general dentists' incorporation of lasers in their practices. Dr. Koceja received his laser certification in 2000, and has since achieved mastership level in the World Clinical Laser Institute (WCLI). As one of the early users of the Waterlase® laser, he is actively involved in the testing and development of new techniques to increase use and awareness of the Waterlase®. Dr. Koceja has also tested various other models of lasers giving him true comparison of what lasers can and cannot do. He is actively involved in the WCLI, including a position on the certification committee. Dr. Koceja is currently practicing in Camas, Wash. He has trained more than 300 dentists to use the Waterlase® and Waterlase® MD dental lasers. Some of the articles Dr. Koceja has written include: "The Laser Helps Us Do Better Dentistry and The Atraumatic Excision and Ablation of Mandibular Tori With the YSGG Laser." Over the past eight years Dr. Koceja has lectured throughout the world on lasers and their incorporation into all aspects of dental practice.

References

1 Hadley J, Young DA, Eversole LR, Gornbein JA. A laser-powered hydrokinetic system for caries removal and cavity preparation. J Am Dent Assoc. Jun. 2000; 131(6):777-85.

2 Wang X, Ishizaki NT, Suzuki N, Kimura Y, Matsumoto K. Morphological changes of bovine mandibular bone irradiated by Er,Cr:YSGG laser: an in vitro study. J Clin Laser Med Surg. Oct. 2002; 20(5):245-50.

3 Eversole LR, Rizoiu IM. Preliminary investigations on the utility of an erbium, chromium YSGG laser. J Calif Dent Assoc. Dec. 1995; 23(12):41-7.

4 Department of Health and Human Services. Laser surgical instrument for use in general and plastic surgery and in dermatology. Jan. 28, 2008. On file: K071734.

5 Biolase® press release. Biolase® Announces FDA 510(k) Clearance of Its Waterlase® MD Laser System for Dermatology. Newswire: Feb. 7, 2008.

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