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. Introduction
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).
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 3/2007 G. OLIVI ET AL.
occasional gingival bleeding at the maxillary right
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
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
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- sues. FIG. 1 - Preoperative full mouth view.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 3/2007 EPULIS REMOVAL WITH LASER TECHNOLOGY 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.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 3/2007 G. OLIVI ET AL. FIG. 9 - Postoperative control after FIG. 10 - Postoperative control FIG. 11 - Postoperative control Discussion Conclusion
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;
short operative time, a very important element of
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The choice to use an Er,Cr:YSGG laser (medium
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EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 3/2007
Backgrounder on Lignans Phytoestrogens are plant chemicals that can have estrogen-like actionsin humans and animals. The main phytoestrogens are isoflavones,coumestans, flavonoids and lignans (139). Lignans are widely distributedin the plant kingdom, play a role in plant growth and act as antioxidantsin human metabolism. In fact, the main lignan in flax and the formsderived from it are all an
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