Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2013; 58: 424–427 doi: 10.1111/adj.12119

Cervicofacial subcutaneous emphysema associated with dental laser treatment S Mitsunaga,* T Iwai,* H Kitajima,* Y Yajima,* T Ohya,* M Hirota,* K Mitsudo,* N Aoki,† Y Yamashita,† S Omura,‡ I Tohnai* *Department of Oral and Maxillofacial Surgery, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama, Japan. †Department of Oral and Maxillofacial Surgery, Saiseikai Yokohamashi Nanbu Hospital, Konan-ku, Yokohama, Japan. ‡Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University Medical Center, Minami-ku, Yokohama, Japan.

ABSTRACT Cervicofacial subcutaneous emphysema is a rare complication of dental procedures. Although most cases of emphysema occur incidentally with the use of a high-speed air turbine handpiece, there have been some reports over the past decade of cases caused by dental laser treatment. Emphysema as a complication caused by the air cooling spray of a dental laser is not well known, even though dental lasers utilize compressed air just as air turbines and syringes do. In this study, we comprehensively reviewed cases of emphysema attributed to dental laser treatment that appeared in the literature between January 2001 and September 2012, and we included three such cases referred to us. Among 13 cases identified in total, nine had cervicofacial subcutaneous and mediastinal emphysema. Compared with past reviews, the incidence of mediastinal emphysema caused by dental laser treatment was higher than emphysema caused by dental procedure without dental laser use. Eight patients underwent CO2 laser treatment and two underwent Er:YAG laser treatment. Nine patients had emphysema following laser irradiation for soft tissue incision. Dentists and oral surgeons should be cognizant of the potential risk for iatrogenic emphysema caused by the air cooling spray during dental laser treatment and ensure proper usage of lasers. Keywords: Cervicofacial subcutaneous emphysema, dental laser treatment, complication. (Accepted for publication 12 March 2013.)

INTRODUCTION Cervicofacial subcutaneous emphysema is a rare complication of dental procedures employing an air turbine or syringe, and dentists and oral surgeons sometimes encounter cases of mediastinal emphysema subsequent to extensive subcutaneous emphysema.1 Heyman and Babayof2 reviewed cases of emphysematous complications in dentistry reported between 1960 and 1993, and McKenzie and Rosenberg3 later reviewed cases of iatrogenic subcutaneous emphysema caused by dental and surgical procedures reported between 1993 and 2008. Most cases were associated with the use of an air turbine or syringe during tooth extraction, restorative treatment, or endodontic treatment; only one case, reported in 2001 by Hata and Hosoda,4 was associated with the use of a dental laser. With the more widespread use of dental lasers and subsequent reports of such complications, we reviewed cases of cervicofacial subcutaneous emphysema associated with dental laser treatment 424

that were reported between January 2001 and September 2012, including cases we encountered clinically. REVIEW OF THE LITERATURE A comprehensive review of reports of cervicofacial subcutaneous emphysema associated with dental laser treatment was performed via PubMed and Ichushiweb (Japan Medical Abstracts Society) for reports published between January 2001 and September 2012, using the keywords ‘subcutaneous emphysema’ and ‘laser’. We then reviewed the literature cited in the articles identified in the search and included clinical cases referred to us for emphysema caused by dental laser treatment. Between January 2001 and September 2012, three patients with cervicofacial subcutaneous emphysema following dental laser treatment were referred to our department. The literature review revealed five cases of emphysema following laser dental treatment in the © 2013 Australian Dental Association

Emphysema associated with dental laser treatment English-language literature (including one of our cases)1,4–7 and seven cases in the Japanese-language literature (including one of our cases).8–14 All 13 cases (one male, 12 females; mean age, 43.6 years; age range, 8–76 years) are summarized in Table 1 and all were reported from Japanese hospitals. Emphysema occurred in five cases after abscess incision and drainage using a dental laser, in two paediatric cases after frenectomy, in two cases following anti-inflammatory laser treatment for periapical infection, and in one case each of subgingival scaling, flap elevation and gingivoplasty. The remaining case involving dental laser treatment of the gingiva provided no description of the diagnosis or dental procedure. Emphysema was caused by the use of CO2 and Er:YAG lasers in eight and two cases, respectively. In another case a YAG laser was used, but the type was not described and in the remaining two cases the type of dental laser used was not stated. The presence of emphysema was determined by computed tomography (CT) in all cases. Twelve of the 13 cases had cervicofacial subcutaneous emphysema, while emphysema was limited to the facial subcutaneous region in the remaining case.14 In nine of the 12 cases with cervicofacial subcutaneous emphysema, the emphysema had extended to the mediastinum. Following emphysema diagnosis, 11 patients were hospitalized for airway and circulation monitoring; there was no description of hospitalization in the other two cases. Serious breathing problems or circulatory problems were not reported in any case. Mean hospitalization was 6.5 days (range 3–12 days). Prophylactic antibiotics were administered in 11 cases, with no description of antibiotics given in two cases, and there were no cases of emphysematous infection. DISCUSSION Although head and neck iatrogenic subcutaneous emphysema is a rare complication of dental procedures employing an air turbine or syringe, there have been cases caused by laser treatment according to recent reports.15,16 While the incidence of cervical emphysema caused by transoral CO2 laser surgery for carcinoma of the larynx and pharynx is reported to be in the range of 1.1% (3/275 cases) to 7.3% (4/55 cases),15,16 the incidence of emphysema caused by dental laser treatment is lower. Dental lasers are now being used more widely in dentistry and oral surgery.17,18 Dental laser treatment has been approved by the US Food and Drug Administration for a number of dental and surgical soft-tissue procedures, including haemostasis, tumour removal, biopsy, crown lengthening, frenectomy, frenotomy, operculectomy, oral papillectomy, vestibuloplasty, exposure of non-erupted or partially erupted © 2013 Australian Dental Association

teeth, pulpotomy, implant recovery, gingivectomy, aphthous ulcer treatment, removal of canal filling material, sulcular debridement, and abscess incision and drainage.17 In Japan, dental laser treatment is now widely performed by dentists and oral surgeons using CO2, Nd:YAG, or Er:YAG lasers. CO2 and Nd: YAG lasers, which are commonly used as high-power lasers, have excellent soft tissue ablation capabilities and afford adequate haemostasis, while Er:YAG lasers are more effective for treating subgingival calculus than ultrasonic scaling19 and have high bactericidal potential,20 and have recently been approved by the Japanese Ministry of Health, Labor, and Welfare for caries removal, cavity preparation, sulcular debridement, and subgingival calculus removal. Dental lasers also enable treatment without anaesthesia21 and are good tools for soft tissue management in children because less medication is needed, intra- and postoperative bleeding is reduced, the need for sutures is reduced, wound healing is faster, and scarring is less pronounced.22 However, alongside the advantages that laser treatment brings, the complication of cervicofacial subcutaneous emphysema has been reported over the past decade.1,4–13 It is now known that subcutaneous emphysema can be caused by inappropriate use of dental lasers with air projection systems.4,5 Of the 13 such cases reviewed here, nine (69.2%) were associated with cervicofacial subcutaneous and mediastinal emphysema. This is a much higher incidence than the range of 36% (27/75 cases) to 53.1% (17/32 cases) for mediastinal emphysema reported in Heyman and Babayof2 and McKenzie and Rosenberg’s3 reviews, respectively, covering the period 1960–2008. In addition, none of those cases were caused by dental laser treatment. Compared with these past reviews, the incidence of mediastinal emphysema caused by dental laser treatment was higher than emphysema caused by dental treatment and oral surgery without dental laser use. This appears to be because dental lasers are commonly used for soft tissue surgery where compressed air may invade through the tissue spaces to the deep soft tissues including the mediastinum more easily than with the use of air turbine or syringe systems for hard tissue dental treatment and oral surgery, such as tooth extraction, restorative treatment, or endodontic treatment. Dental lasers use a compressed air stream for cooling the operative site and supply the air at the rate of 6 to 9 L/min.7 The Er:YAG laser manual suggests that air pressure towards the laser tip be lowered or turned off when irradiating a gingival sulcus1; however, even if turned off, moderate air will continue to flow towards the tip for the purposes of cooling and protection.1 Furthermore, when CO2 or Nd:YAG lasers are used for soft tissue incision, a stream of cool air 425

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

*our case. NA: not available.

11 46 34 16 36 36 14 14 NA 26 14 D (2001) I (2006) J (2006) K (2007) H* (2007) L (2009) E (2009) F (2010) M (2010) N (2011) G (2012) A* (2012) * 1 2 3 4 5 6 7 8 9 10 11 12 13

19/F 58/F 40/F 60/F 48/F 39/F 49/F 64/F 35/F 9/F 8/F 76/F 62/M

Dentoalveolar abscess Periapical infection Gingival swelling Dentoalveolar abscess Dentoalveolar abscess Periapical infection Periapical infection Dentoalveolar abscess NA Superior labial frenulum Superior labial frenulum Periodontitis Dentoalveolar abscess

Abscess incision Anti-inflammation Gingivoplasty Abscess incision Abscess incision Anti-inflammation Flap elevating for apicoectomy Abscess incision NA Frenectomy Frenectomy Subgingival scaling Abscess incision

CO2 NA CO2 Er:YAG CO2 CO2 CO2 Nd:YAG or Er:YAG NA CO2 CO2 Er:YAG CO2

Cervicofacial subcutaneous

Gas distribution Laser Dental procedure Diagnosis Tooth No. Age, y/ Gender Reference No. (Year) No.

Table 1. Reported cases of emphysema caused by dental laser treatment 426

Facial subcutaneous

Mediastinum

NA 7 3 12 10 4 6 6 10 3 NA 5 6

Hospitalization (Days)

+ NA + + + NA + + + + + + +

Antibiotics

S Mitsunaga et al. may well be needed to alleviate pain from the heat generated. In this review, nine cases had emphysema following laser irradiation for soft tissue incision, such as abscess incision and drainage, frenectomy, flap elevation, and gingivoplasty. Although the air pressure generated by a dental laser is lower than that generated by an air turbine, the duration of tip insertion might be related to the risk of emphysema.6 According to one dental laser manual, incision should first involve cutting part of the swollen gum to provide an opening with the laser and to secure drainage.6 Additionally, the laser should be advanced and retracted without the tip being fixed in the same position in the submucosal tissue.6 The several advantages of dental laser treatment mean that it is now commonly performed in dental clinics,6,17,18 and the potential for iatrogenic emphysema might have increased with inadvertent manipulation of compressed air-equipped lasers.5,7 Prevention of laser-induced emphysema when accessing a closed or narrow cavity, such as a submucosal abscess or surgical defect, requires careful adjustment of the assist airflow and the avoidance of focused and prolonged laser irradiation.1,4–7 Therefore, dentists and oral surgeons should keep in mind that emphysematous complications can be caused by compressed air during dental laser treatment and ensure they adhere to the proper usage of dental lasers. Any procedures should be stopped immediately a patient expresses discomfort, a sensation of swelling, or pain. When emphysema is suspected, they should arrange for a CT scan from the face to the chest to identify the extent of any possible emphysema. Three-dimensional CT images in particular clearly illustrate the volume of air diffused into the soft tissues.7 Antibiotics were administered in some cases of confirmed emphysema as air introduced from an intraoral site may carry bacteria that can potentially lead to the rapid spread of cellulitis or necrotizing fasciitis.3 In McKenzie and Rosenberg’s review,3 20 of 32 patients received antibiotics after subcutaneous emphysema was diagnosed. Although most of those cases, with or without antibiotic therapy, were not complicated by infection, there was a rare case of focal alveolitis that developed after antibiotic therapy. Our review found no cases of emphysematous infection after the prophylactic administration of antibiotics, and supports the need to administer antibiotics prophylactically in confirmed cases of emphysema. REFERENCES 1. Mitsunaga S, Iwai T, Yamashita Y, et al. Cervicofacial subcutaneous and mediastinal emphysema caused by air cooling spray of dental laser. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:e13–16. © 2013 Australian Dental Association

Emphysema associated with dental laser treatment 2. Heyman SN, Babayof I. Emphysematous complications in dentistry, 1960–1993: an illustrative case and review of the literature. Quintessence Int 1995;26:535–543. 3. McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: a literature review. J Oral Maxillofac Surg 2009;67:1265–1268. 4. Hata T, Hosoda M. Cervicofacial subcutaneous emphysema after oral laser treatment. Br J Oral Maxillofac Surg 2001; 39:161–162. 5. Imai T, Michizawa M, Arimoto E, Kimoto M, Yura Y. Cervicofacial subcutaneous emphysema and pneumomediastinum after intraoral laser irradiation. J Oral Maxillofac Surg 2009;67:428– 430. 6. Matsuzawa N, Kinoshita H, Shirozu T, Takamura M, Nagao T. Mediastinal emphysema caused by a dental laser. Asian J Oral Maxillofac Surg 2010;22:216–219. 7. Suzuki J, Takahashi S. Subcutaneous emphysema and pneumomediastinum due to carbon dioxide laser therapy. J Pediatr 2012;161:167. 8. Hirashita K, Matsui Y, Ozawa T, Iwai T, Ishibashi K, Tohnai I. A case of emphysema arising on face, neck, and mediastinum after CO2 laser irradiation for an alveolar abscess. Jpn J Oral Maxillofac Surg 2007;53:319–323 (in Japanese). 9. Kusama M, Takahashi J, Osano H, Watanabe H. A case of subcutaneous emphysema in the face and neck caused by root canal therapy with a dental laser. J Tochigi Dent Assoc 2006;58:17–19 (in Japanese). 10. Mizoguchi Y, Nagamatsu T, Ikebe H. Mediastinal emphysema caused by dental treatment. Sasebo City Gen 2006;32:51–53 (in Japanese). 11. Ro Y. Subcutaneous emphysema following dental treatment. J Tokyo Dent College Soc 2007;107:272–276 (in Japanese). 12. Imai T, Michizawa M. A case of cervicofacial subcutaneous and mediastinum emphysema caused by dental CO2 laser for anti-inflammation. J Osaka Univ Dent Soc 2009;54:29–32 (in Japanese). 13. Saito T, Kusunoki T, Takayanagi H, Ikeda K. Two cases of cervical subcutaneous emphysema following dental treatment. Practica oto-rhino-laryngologica 2010;126:42–45 (in Japanese).

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14. Araki S, Sawai F, Miki H, Meguro K, Wada K, Iwasaki A. A case of subcutaneous emphysema developed after resection of the upper labial frenum using CO2 laser. J Pediatr Oral Maxillofac Surg 2011:82–85 (in Japanese). 15. Vilaseca-Gonzalez I, Bernal-Sprekelsen M, Blanch-Alejandro JL, Moragas-Lluis M. Complications in transoral CO2 laser surgery for carcinoma of the larynx and hypopharynx. Head and Neck 2003:382–388. 16. Kutter J, Lang F, Monnier P, Pasche P. Transoral laser surgery for pharyngeal and pharyngolaryngeal carcinomas. Arch Otolaryngol Head Neck Surg 2007;133:139–144. 17. Convissar RA, Goldstein EE. An overview of lasers in dentistry. Gen Dent 2003;51:436–440. 18. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am 2004;48:861–888. 19. Aoki A, Miura M, Akiyama F, et al. In vitro evaluation of Er: YAG laser scaling of subgingival calculus in comparison with ultrasonic scaling. J Periodontal Res 2000;35:266–277. 20. Ando Y, Aoki A, Watanabe H, Ishikawa I. Bactericidal effect of erbium YAG laser on periodontopathic bacteria. Lasers Surg Med 1996;19:190–200. 21. Komori T, Yokoyama K, Takato T, Matsumoto K. Case reports of epulis treated by CO2 laser without anesthesia. J Clin Laser Med Surg 1997;14:189–191. 22. Boj JR, Poirier C, Hernandez M, Espassa E, Espanya A. Review: laser soft tissue treatments for paediatric dental patients. Eur Arch Paediatr Dent 2011;12:100–105.

Address for correspondence: Dr Toshinori Iwai Department of Oral and Maxillofacial Surgery Yokohama City University Graduate School of Medicine 3–9 Fukuura, Kanazawa-ku Yokohama 236-0004 Japan Email: [email protected]

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Cervicofacial subcutaneous emphysema associated with dental laser treatment.

Cervicofacial subcutaneous emphysema is a rare complication of dental procedures. Although most cases of emphysema occur incidentally with the use of ...
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