Journal of Cosmetic and Laser Therapy, 2014; Early Online: 1–4

CASE REPORTS AND SHORT REPORT

The use of surgical Nd:YAG laser in an oral pyogenic granuloma: A case report

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GÜLHAN KOCAMAN1, NIHAL BELDÜZ2, CEREN ERDOGAN3, ELVAN OZBEK4, ELIF SADIK5 & CANKAT KARA3 1Faculty

of Dentistry, Atatürk University, Periodontology, Erzurum, Turkey, 2Faculty of Dentistry, Ordu University, Pedodontics, Ordu, Turkey, 3Faculty of Dentistry, Ordu University, Periodontology, Ordu, Turkey, 4Department of Histology and Embryology, Faculty of Medicine, Sakarya University, Sakarya, Turkey, and 5Faculty of Dentistry, Ordu University, Oral and Maxillofacial Radiology, Ordu, Turkey

Abstract Pyogenic granuloma is a benign, non-neoplastic, mucocutaneous lesion and is especially common on the tongue, lips, and gums. This case report presents a large oral pyogenic granuloma of the gingiva and the surgical treatment of this lesion with Nd:YAG laser. A 14-year-old female patient referred with a complaint of a swelling and growth on the buccal side of her mandibular left premolar teeth. A comprehensive intraoral examination revealed a localized gingival mass between mandibular left premolar teeth on the buccal aspect. The treatment selected was surgical removal using Nd:YAG laser with the following irradiation parameters: power output 4 W, energy 100 mJ, frequency 40 Hz, and pulsed emission mode. During surgery, complications including hemorrhage were not observed, and no scarring developed after surgery. The excised area gradually improved within 1 month. The use of Nd:YAG laser in the treatment of pyogenic granuloma reduced bleeding during surgery, with a consequent reduction in operating time, promoted rapid postoperative hemostasis, and has better patient acceptance. Key Words: laser in dentistry, Nd:YAG laser, oral pyogenic granuloma

Introduction Pyogenic granuloma is a relatively common, soft tissue tumor of oral cavity that is believed to be reactive and not neoplastic in nature (1). The pyogenic granuloma is thought to represent an exuberant tissue response to local irritation or trauma. Pyogenic granuloma is a well-known oral lesion (2,3). However, some authors use the term, “lobular capillary hemangioma” for this lesion (4) or the terms, “vascular epulis”, “benign vascular tumour”, “hemangiomatous granuloma”, and “pregnancy tumour” when it occurs in pregnant women. Clinically, these lesions appear as soft mass, smooth or lobulated, and sessile or pedunculated and may vary in size from a few mms to several cms (5). Vascular malformations of the oral cavity, though uncommon, are a discomforting and potentially serious clinical problem. Patients often present with complaints of recurrent hemorrhage, biting of oral

tissue, pain, and difficulty with speaking, mastication, and deglutition (6). Many different modalities for treatment of vascular lesions have been used so far: surgical, cryosurgery, electrodessication, intralesional administration of corticosteroids or sclerosant (sodium tetradecyl), radiotherapy, and embolization with steel coil, gel foam, silicone beads, or cyanoacrylate (1,7). Total excision is the only definitive treatment for vascular anomalies. In the past decade, therapy with the Nd:YAG laser has emerged as new alternative (7). The laser energy is selectively absorbed by hemoglobin and converted to heat, coagulating the designated vessels in combination with an adequately long pulse width (8). In dentistry, soft tissue surgery using the Nd:YAG laser has been widely accepted, and its purported advantages versus scalpel surgery have been enumerated by various authors: increased coagulation, which yields a dry surgical field and better visualization; the

Correspondence: Cankat Kara, Ph.D, Faculty of Dentistry, Periodontology, Ordu Üniversitesi Dis¸ Hekimlig˘ i Fakültesi, Ordu 52100, Turkey. Tel: 90452 212 1286. Fax: 90452 212 1289. E-mail: [email protected] (Received 24 July 2013 ; accepted 19 January 2014 ) ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd. DOI: 10.3109/14764172.2014.910078

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ability to negotiate curvatures and folds within tissue contours; tissue surface sterilization; decreased swelling and edema, decreased pain, and increased patient acceptance (9,10). In the present case study, we report a rare and an unusual case of pyogenic granuloma of the gingiva and describe the successful treatment of this case with the long-pulsed Nd:YAG laser.

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Case report A 14-year-old female patient reported with a complaint of a swelling and growth on the buccal side of her mandibular left premolar teeth. She also complained of localized bleeding in that area, and there was moderate pain and discomfort on eating and brushing. The medical history indicated that the patient has in good health, with no previous systemic diseases. A comprehensive intraoral examination revealed a localized gingival mass between mandibular left premolar teeth on the buccal aspect (Figure 1). The mass was bright red, erythematous and lobulated with well-defined margins. Periodontal examination revealed a mild and generalized gingivitis. There was no clinical attachment loss. Before surgical treatment of the lesion, the patient underwent scaling to remove any local irritating factors that may have been responsible for the gingival inflammation. A Nd:YAG laser was used to perform the laser surgery (Smarty A10; DEKA, Firenze, Italy; pulsed wave laser with a wavelength of 1064 nm under air cooling) with the following irradiation parameters: power output 4 W, energy 100 mJ, frequency 40 Hz, pulsed emission mode. The laser beam was conducted by an optical fiber with a 320-μm spot size in contact mode. Surgery was performed under local anesthesia (articain 4% with 1:200.000 epinephrine Ultracain D-S Forte; Aventis Pharma, Istanbul, Turkey). The lesion was held with a hemostat and the upper and lower portions of the lesion were incised by applying laser energy via a fiberoptic probe. The excised area bled slightly, and then coagulated within 5 s. The Nd:YAG laser produced a relatively thick coagulation layer on the excision

Figure 1. Intra-oral view of the lesion before the treatment.

Figure 2. Light micrographs of the pyogenic granuloma. ca: capillaries; e: endothelial cells of the capillary vessel; bc: blood cells within the capillaries; v: large vessel; ct: connective tissue fibers; Histologic stains: (A) Masson’s trichrome; (B) H&E. Objective magnifications:  20.

surface, due to the laser’s penetration and thermogenesis. No sutures were placed after laser surgery. The excised lesion was stored in 10% formalin and sent for histopathological examination. Light microscopic sections of the tissue sample embedded in paraffin wax were stained with Hematoxylin and Eosin (H&E) and Masson’s trichrome techniques. Histologic structure of the lesion was characterized with lots of enlarged or normal-size capillary blood vessels surrounded by inflammatory fibrous septae (Figures 2 and 3). On the basis of clinical examination and histopathology, a diagnosis of lobular capillary hemangioma (pyogenic granuloma) was made. At 1-week postsurgical follow-up, the wound was observed to be healed uneventfully. The patient experienced mild postoperative pain and swelling. There was no observable scarring and no ulceration (Figure 4A). The excised area gradually improved

Figure 3. Light micrographs of the pyogenic granuloma. ca: capillary vessels; m: myxoid matrix formation within the connective tissue; f: fibroblast-like cells with a huge nucleus; pnl: polymorhonuclear leukocytes; p: plasma cells. Histologic stains: (A) H&E; (B) Masson’s trichrome. Objective magnifications:  40.

Laser treatment of pyogenic granuloma

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Figure 4. Clinical aspect of pyogenic granuloma (A) 1 week and (B) 1 month after laser surgery.

within 1 month (Figure 4B). There were no significant complications, such as bleeding, severe pain, or delayed wound healing. The patient was also reviewed 3 months after the laser surgery, and there was no recurrence of the lesion.

Discussion Pyogenic granuloma is a well-known oral lesion. The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically (11). Oral pyogenic granuloma pose distressing problems to the patients, producing cosmetic deformity, recurrent hemorrhage, and functional problems with speaking, deglutition, and mastication (6). Oral pyogenic granulomas are susceptibility to minor trauma and consequent bleeding and ulceration, swallowing difficulties and breathing problem; although, the major concern is cosmetic in most cases (2,5,6). In our case, a localized lobular gingival mass with welldefined margins was seen (pyogenic granuloma). The clinical appearance of this oral lesion is similar to that of many other vascular lesions as described in the literature (2–4,11,12). Various treatment modalities are suggested for these lesions including surgical, cryosurgery, intralesional administration of corticosteroids or sclerosant (sodium tetradecyl), radiotherapy, and embolization with steel coil, gel foam, silicone beads or cyanoacrylate (1). However, oral vascular lesions have a relatively high incidence, can be very troublesome to the patient, and are often difficult to remove. Although surgical resection with or without embolization has been advocated for oral vascular lesions, the complications of scarring and bleeding are frequently seen after the excision procedure (13). Commonly, however, vascular lesions, especially extensive and diffuse lesions, are refractory to these therapies, which may cause significant side effects above described. The use of laser energy as a therapeutic option offers a more conservative, yet effective approach in the treatment of vascular lesions. The Nd:YAG laser can serve as an effective treatment tool as long as certain general precautions and limitations are observed (7,14,15).

In the present case report, the advantage of a Nd:YAG laser usage has been in terms of a virtually bloodless surgical field as a result of the hemostatic mechanism of the laser, providing an excellent visualization of the area and facilitates an accurate resection of the lesion with suitable margins. The ability of a Nd:YAG laser to negotiate curvatures and folds within the tissue contours; tissue surface sterilization and swelling, edema and scarring, due to sealing of small lymphatic vessels and less inflammatory response: decreased pain also due to effects on the nerve endings; faster healing response and increased patient acceptance (16). Lasers with a wide range of characteristics are available today and are being used in the various fields of medicine and dentistry (17–19). The Nd:YAG laser therapy is an effective treatment for hemangiomas and vascular malformations as an alternative to conventional strategies (17). The Nd:YAG laser is known for its high tissue penetration of up to 1 cm and scattering of laser light with a blood vessel coagulation effect, and it is considered to be an appropriate laser for treatment of voluminous hemangiomas (16,17). In our treatment, the Nd:YAG laser was chosen over the other devices because of its greater specificity for hemoglobin. We felt that more selective and safer photocoagulation could be performed using a Nd:YAG laser. For routine clinical dental treatments, pain control is quite important for patient physical and mental well-being, as well as for the effectiveness of therapy. The conventional surgery procedures for vascular lesions involved creating a wound after incision, often with copious bleeding, and suturing to close the wound. Patients often experience postoperative pain, bleeding, and discomfort, particularly due to the sutures. In addition, suture removal after 1 week may be painful because the sutures may become buried in the mucosa. In our postoperative instructions after the conventional surgeries with scalpel, we recommend patients to use over-the-counter analgesia such as paracetamol and non-steroidal anti-inflammatories as necessary within the recommended dose to reduce serious discomfort. By contrast, the distinct advantages of Nd:YAG laser surgery include the fact that the laser can cut more precisely, meaning that removal

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of unwanted tissues is relatively bloodless; the laser also sterilizes as it cuts, thus reducing the risk of blood-borne disease transmission and reducing rates of postoperative infection. Also, post-surgical pain and swelling are minimized, and there is less wound contraction during healing, meaning that there is less mucosal scarring. No suturing is needed, operative time is reduced, and there is no damage to adjacent healthy tissues. As a result patients treated with Nd:YAG laser surgery have significantly less postoperative pain, fewer functional complications, and less fear compared to conventional surgery. Some reports also suggest that laser-induced wounds heal more quickly and produce less scar tissue than those inflicted in conventional surgery (20), although contrary evidence also exists (21,22). In an animal model study, it was shown that there was initial wound repair in the laser incision was slower than with the scalpel incision, but after 21 days, both incisions showed the same clinical characteristics. However, the vaporized incision showed no tissue trauma and no hemorrhagic complications, unlike the sutured incision (23). Angiero et al (24). found that forced dehydration with induced photocoagulation treatment of the oral vascular lesions provided effective management, avoids recurrence, and shortens healing time. In an another study, the treatment of intra-oral hemangiomas with CO2 laser, no complications were seen postoperatively but the healing period was prolonged (25). In our case, the use of Nd:YAG laser in the treatment of pyogenic granuloma reduced bleeding during surgery, with a consequent reduction in operating time, and promoted rapid postoperative hemostasis. Postoperative problems, including potential scarring, and discomfort were not observed. Conclusion Laser treatment is quick, bloodless, safe, and easy to learn. Postoperative problems and discomfort are minimal, and so is scarring. With this method we can considerably reduce the risks during and after the surgical intervention because of the minimal bleeding during the surgery and also because of the rapid healing without any complications. When used appropriately, the Nd:YAG laser is a very useful tool for removal of vascular lesions. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. References 1. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012; 16:79–82. 2. Mahabob N, Kumar S, Raja S. Palatal pyogenic granuloma. J Pharm Bioall Sci. 2013;5:179–181.

3. Akyol MU, Yalçiner EG, Dog˘an AI. Pyogenic granuloma (lobular capillary hemangioma) of the tongue. Int J Pediatr Otorhinolaryngol. 2001;58:239–241. 4. Kamala KA, Ashok L, Sujatha GP. Pyogenic granuloma on the upper labial mucosa: a case report. J Clin Diagn Res. 2013;7:1244–1246. 5. Buckmiller LM, Richter GT, Suen JY. Diagnosis and management of hemangiomas and vascular malformations of the head and neck. Oral Dis. 2010;16:405–418. 6. Açıkgöz A, Sakallioglu U, Ozdamar S, Uysal A. Rare benign tumours of oral cavity-capillary hemangioma of palatal mucosa: a case report. Int J Paediatr Dent. 2000;10:161–165. 7. Shapshay SM, David LM, Zeitels S. Neodymium-YAG laser photocoagulation of hemangiomas of the head and neck. Laryngoscope. 1987;97:323–330. 8. Adrian RM. Treatment of leg telangiectasias using a longpulse frequency-doubled neodymium:YAG laser. Dermatol Surg. 1998;24:19–23. 9. Kara C, Süleyman H, Tezel A, Orbak R, Çadırcı E, Polat B, Kara I˙. Evaluation of pain levels after Nd: YAG laser and scalpel incisions: an experimental study in rats. Photomed Laser Surg. 2010;28:635–638. 10. Kara C. Evaluation of patient perceptions of frenectomy: a comparison of Nd: YAG laser and conventional techniques. Photomed Laser Surg. 2008;26:147–152. 11. Gomes SR, Shakir QJ, Thaker PV, Tavadia JK. Pyogenic granuloma of the gingiva: a misnomer? - a case report and review of literature. J Indian Soc Periodontol. 2013;17:514–519. 12. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48:167–175. 13. Qing Y, Cen Y, Xu X, Duan W, Liu Y. Surgical treatment of hemangioma and vascular malformation in body surface. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009;23: 325–327. 14. Miyazaki H, Kato J, Watanabe H, Harada H, Kakizaki H, Tetsumura A, et al. Intralesional laser treatment of voluminous vascular lesions in the oral cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:164–172. 15. Werner JA, Lippert BM, Gottschlich S, Folz BJ, Fleiner B, Hoeft S, Rudert H. Ultrasound-guided interstitial Nd:YAG laser treatment of voluminous hemangiomas and vascular malformations in 92 patients. Laryngoscope. 1998;108:463–470. 16. Bradley PF. A review of the use of the neodymium YAG laser in oral and maxillofacial surgery. Br J Oral Maxillofac Surg. 1997;35:26–35. 17. Goldberg DJ. Laser treatment of vascular lesions. In: Laser dermatology. Berlin, Heidelberg: Springer; 2005. p. 13–35. 18. Anderson PR. Laser - tissue interactions. In: Cutaneous laser surgery. St. Louis, Missouri: Mosby Inc; 1999. p. 13–18. 19. Adams TC, Pang PK. Lasers in aesthetic dentistry. Dent Clin North Am. 2004;48:833–860. 20. Fisher SE, Frame JW, Browne RM, Tranter RMD. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch Oral Biol. 1983;28:287–291. 21. Buell BR, Schuller DE. Comparison of tensile strength in CO2 laser and scalpel skin incisions. Arch Otolaryngol. 1983;109:465–467. 22. Frame JW. Removal of oral soft tissue pathology with the CO2 laser. J Oral Maxillofac Surg. 1985;43:850–855. 23. Paes-Junior TJ, Niccoli-Filho W. Clinical comparison between conventional sture and vaporization with carbon dioxide laser in rat’s skin. J Clin Laser Med Surg. 2001;19:319–324. 24. Angiero F, Benedicenti S, Romanos GE, Crippa R. Treatment of hemangioma of the head, and neck with diode laser, and forced dehydration with induced photocoagulation. Photomed Laser Surg. 2008;26:113–118. 25. Lambrecht JT, Stübinger S, Hodel Y. Treatment of intraoral hemangiomas with the CO2 laser. Schweiz Monatsschr Zahnmed. 2004;114:348–359.

The use of surgical Nd:YAG laser in an oral pyogenic granuloma: a case report.

Pyogenic granuloma is a benign, non-neoplastic, mucocutaneous lesion and is especially common on the tongue, lips, and gums. This case report presents...
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