Removal of fibrous epulis with Er,Cr:YSGG
laser: case report
G. OLIVI, M. COSTACURTA, P. MATURO, R. DOCIMO ABSTRACT. Background Epulis is a benign tumour located in the area of the alveolar bone, periodontal ligament
and marginal gingiva. A clinical case of Epulis, treated using an Er,Cr:YSGG laser in our Paediatric Dentistry
division of the PTV Hospital, University of Rome “Tor Vergata”, is described. Case report A pink, sessile,
broad-based lesion, elastic in consistency, was detected on the maxillary vestibular gum above the lateral right
incisor. The lesion was removed with Er,Cr:YSGG laser (2780 nm) without anaesthetic infiltration, power ranged
from 1,5 to 2,0 Watts at 20 Hz repetition rate under 20%-15% air-water spray. The histopathological
examination confirmed the diagnosis of fibrous epulis. The immediate postoperative course was excellent, with
no pain or need for anti-inflammatory or analgesic drugs. Wound healing was good after 1 week, and was
completed after 1 month. The patient was followed up for 3-6 months, and checked again after 1 and 2 years to
assess possible relapse. The Er,Cr:YSGG laser has several treatment advantages, fundamental in Paediatric
Dentistry: it requires only topical anaesthesia, it has a high clinical safety, there is a short treatment time, no
surgical sutures are required; no complications were encountered during or immediately following laser surgery,
all resulting in excellent patient cooperation.

KEYWORDS: Er,Cr:YSGG laser, epulis, oral hyperplastic lesions.
factors (chronic gingivitis, periodontal disease, Epulis is an aspecific clinical term of topographic defective dental fillings, poorly fitting dentures, poor meaning (επι over, ουλον gums) but without specific oral hygiene, tobacco smoking), blood dyscrasias histological characteristics; in clinical terminology it is (anaemias, haemostatic alterations) and hormonal used to describe benign tumours, circumscribed and influences (during pregnancy, due to an increase in located in the area of the gums or near the alveolar estrogen and progesterone levels) [Tamarit-Borràs et al., 2005]. The treatment aim is to remove the According to the histopathological classification aetiologic factors and the surgical excision of the [Anneroth and Sigurdson, 1983], epulis are divided into three large groups:1. granulomatous hyperplasia: epulis in pregnancy, Materials and methods
In the case reported an Er,Cr:YSGG laser, 2780 nm (Waterlase, Biolase-Irvine, CA-U.S.) was used. This 2. fibrous hyperplasia: fibrous epulis, fissured epulis, medium infrared laser works in pulse mode, at a fixed frequency of 20 pulses per second (Table 1) [Hadley, 2000] (0-6W power 140 microsec. pulse duration).
The Er-Cr laser has a close affinity with The aetiology of epulis is multifactorial: irritative hydroxyapatite and water, so it can be used both onhard (tooth, bone) and soft tissues (mucosa, gum, pulptissue) [Iaria et al., 2005]. Therefore considering the PTV Hospital - University of Rome “Tor Vergata”, Rome, Italy high water content of soft tissues, the therapeutic e-mail: [email protected] indications of Er-Cr laser on such area are several(Table 2).
occasional gingival bleeding at the maxillary right Parameters
lateral incisor area, when chewing or during homedental care. The intraoral clinical examination revealed a vestibular gingival neoformation above the maxillary right lateral incisor that extended from the central incisor to the deciduous canine; it was pinkish, sessile, wide-based, fixed but elastic in consistency, covered by apparently healthy mucous tissue (Fig. 1, The lateral incisor responded positively to pulp vitality tests. Orthopantomography and periapical X-rays were within normal ranges (Fig. 2).
TABLE 1 - Operative parameters of the Er,Cr:YSGG laser
The clinical appearance was consistent with a (Waterlase, Biolase-Irvine, CA-U.S.). diagnosis of a benign fibrous tumour with slightvascularisation, localised in the gingival area withoutinvolving the alveolar margin.
The coefficient of water absorption of the 2780 nm The treatment plan was outlined as follows: radiation is slightly lower than 2940 nm radiation complete removal of the lesion by means of laser [Caprioglio et al., 2003) with a similar effective action surgery, using Er,Cr:YSGG laser (Waterlase, Biolase- on soft tissues. The adjustable air-water spray Irvine, CA-U.S.) with a minimally invasive approach.
delivered through a handpiece produces a clean The treatment plan was fully explained to the patient incision and vaporisation (cleaning effect) and avoids and parents, and all associated risks were outlined: a a rise in the temperature of the tissue (cooling effect) written consent form was signed by the parents in the Soft tissue anaesthesia was induced with topical 15% lidocaine spray, initial laser settings were at low Case report
power (0,5-0,75 Watts - 20 Hz) in defocused mode, An 11-year old boy was seen in the Paediatric slowly irradiating the area to induce analgesia, that Dentistry division of the PTV Hospital, University of means, a relative increase of the membrane potential of the sensitive nerve cells (hyperpolarisation), to A clinical examination chart was completed with avoid them being stimulated [Benedicenti, 2005].
patient personal details, medical history, extra- The power was then slowly increased to 1,5-2,0 intraoral clinical examination, x-rays and photographs.
Watts - 20 Hz, with an air-water spray ratio of 20%- The patient’s dental history revealed pain and 15%, gradually progressing to the contact mode with aclean, fast incision and excision of the neoformation(Fig. 5, 6).
The incision was carried out using a conical sapphire Indications
Periodontal treatment by pocket’s decontamination Treatment of oral pathologies: fibroma, mucocele, epulis, lipoma, papilloma, Aphthous-herpetic stomatitis, hyperkeratosis Removal of inflammatory tissue and foreign body TABLE 2 - Therapeutic indications of Er-Cr laser on soft tis-

FIG. 1 - Preoperative full mouth view.
FIG. 2 - Preoperative panorex.
FIG. 3 - Fibrous epulis, occlusal view.
FIG. 4 - Fibrous epulis.
FIG. 5, 6, 7 - Er,Cr:YSGG laser epulis removal.
tip (T4-400 µm diameter) and then a 14 mm long confirmed that there had been no postoperative quartz tip (Z4-400 µm diameter) was used for sulcus complications or discomfort. No pharmacological gingival curettage and control of the radicular cement. The residual area was finally treated at 0,25 Watt, At one month the tissue had healed completely 0% water and 10% air to achieve haemostatic effect with no scarring (Fig. 10); later follow ups (3-6 (Fig. 7); surgical sutures were unnecessary. months, 1-2 years) failed to reveal any sign of relapse Treatment time required to complete the surgery was approximately 7 minutes. Post-surgical instructions tothe parents and patient included proper home care anda chlorhexidine gel (0,2%) to apply to the wound(twice a day for one week) was prescribed.
The biopsy identified the lesion as removed by a laser, it was 1x0,8x0,4 cm in size, and stored in 10%formalin solution: the histological report confirmed areactive papillary hyperplasia mainly at the fibrousstage, compatible with a diagnosis of fibrous epulis(Fig. 8).
Postoperative follow-up appointments after 1 week and 1 month aimed at evaluating healing and woundrecovery. The patient was seen for further evaluation at3-6 months and 1-2 year to assess possible relapse. A week after the operation the surgical area had not healed completely (Fig. 9). The patient’s parents FIG. 8 - Histological section corresponding to fibrous epulis.
FIG. 9 - Postoperative control after
FIG. 10 - Postoperative control
FIG. 11 - Postoperative control
Laser surgical technique used in this case presented The laser technique used in this study was an effective choice. The therapeutic success was due to less local anaesthetic required: in this case only the positive psychological approach and to the good intraoperative cooperation of the patient; the no analgesic or post surgical anti-inflammatory asymptomatic postoperative follow up without complications led to a better acceptance of this laser the laser’s bactericidal action and lack of collateral surgical treatment by the young patient and parents.
damage reduced the inflammatory reaction: noswelling or infective complication developed inthis cases; References
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considering the slight vascularisation and fibrous Montagna F, Ferronato G, Martinelli F. Patologia orale orientata per nature of the lesion and the advantages of working on problemi: diagnosi differenziale e terapia. Promoass; 2000. p. 241- the gingival tissue and radicular cement without causing lateral or in-depth thermal damage, the Er,Cr Olivi G, Genovese MD. Utilizzo del laser in terapia conservativa.
laser works efficiently as a surgical laser.
Agorà Odontoiatrica 2004;3(4):28-37.
Due to the low power setting used, to the fibrous Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium: nature of the lesion and to the absence of lateral or yttrium, scandium, gallium, garnet laser on mucocutanous soft deep thermal damage of this laser wavelength, a good tissues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996 haemostatic control was achieved for the superficial thermal effect (photo-thermal induced coagulation) of Tamarit-Borràs M, Delgado-Molina E, Berini-Aytés L, Gay-Escoda C.
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Source: http://www.inlaser.it/italiano/pdf/od_infantile/EJPD_LASER_EPULIS.pdf


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