Article Type : Case Report
Authors : Gupta G, Kumar Gupta D, Gupta P, Gupta N and Singh Rana K
Keywords : Diode laser; Excisional biopsy; Leukoplakia; White lesion; Histopathology
In the past few decade there has seen a
veritable explosion of research into the clinical applications of LASER (light
amplification by stimulated emission of radiation) in dental practice, and with
an international focus, the parallel emergence of organizations to support
laser dentistry. Lasers are used an adjunct or alternative to traditional
approaches in the modern dental practice. This case report of leukoplakia
successfully treated with diode laser at 940nm.
White plaques of questionable risk having excluded
(other) known diseases or disorders that carry no increased risk for cancer is
known as Leukoplakia [1]. The predisposing factors for leukoplakia are smoking,
alcohol consumption, physical irritants, galvanism, chronic trauma, poor oral
hygiene, and micro-organisms like candida albicans and human papilloma virus
(HPV) [2].
The estimated average malignant transformation rate of
leukoplakia is 5% to 6% or more depending on the time of observation. Dysplasia
appears to be the best predictor of malignant potential. Not any specific
clinical appearance is there for Dysplastic lesions. In any case, the clinical
appearance is not indicative of the histology [3].
Discontinuation of habits, vitamin supplements, diet
rich in nutritive value, surgical treatment modalities, antifungal and
chemotherapeutic agents have been tried with various results is required for
the management of oral leukoplakia. If the lesion is small, excisional biopsy
is recommended. For histopathological evaluation it is advisable to perform
incisional biopsy of larger lesions that will guide further decisions on the
treatment or cryosurgery and laser ablation can also be done.
A combination of Gallium (Ga), Arsenide (As) and other
elements such as Aluminum (Al) and Indium (In) is used by Diode laser to change
electrical energy into light energy and is a solid-state semiconductor. The
wavelength range is about 810-980 nm, the laser is emitted in continuous wave
and gated pulsed modes and is usually operated in a contact method using a
flexible quartz optic delivery system [4].
In soft tissue surgery use of
this instrument in a continuous wave or pulsed mode greatly increases its
usefulness. The laser is indicated for surgery of oral soft tissues close to
dental structures that does not involve excessive bleeding as it has low absorption
in dental hard tissues and high absorption in tissues pigmented with
hemoglobin, melanin, and collagen chromophores. Advantages of Diode lasers are
- they are small, portable, and inexpensive, the optical fiber delivery system
touches the soft tissue and can be used for ablation, incision, and excision
(cutting, vaporization, curettage, coagulation, and hemostasis), [5] better
postoperative tissue healing and reduction of scar tissue formation due to
decreased collateral tissue damage and fewer myofibroblast cells in laser
wounds. This case report presents a case of leukoplakia treated successfully
with the application of diode laser at 940nm.
A 43-year-old female patient reported with growth in between upper front teeth. On oral examination white linear continuous patch above, maxillary teeth were also seen (Figures 1). It was a recurrent lesion which got previously operated 5 years & 10 years back with histopathological report confirming as leukoplakia both the time. No history of tobacco or any medication. First time it appeared was after her pregnancy with very small lesion.
Figure 1: Pre-operative picture of patient.
Figure 2: After Excisional biopsy of lesion.
Excisional biopsy
was carried out by the application of the diode laser at 940nm wavelength.
After adequate local anesthesia was achieved (2% lidocaine HCl), incision was
placed with the fiber optic tip of the semiconductor diode laser. The incision
was performed at 2.5W and with the contact mode.
Necessary precautions were taken such as eye wear for the patient, operator, and the assistant. Procedure was performed according to the manufacturer’s recommendations and the treatment needs of the patient. With the help of gauze carbonized layer was wiped and the operating area was kept clean. The entire lesion was excised, and the excised specimen was sent for histopathological examination.
Figure 3: After oral prophylaxis.
Oral leukoplakia is usually seen in middle aged and
older men than female, with an increasing prevalence with age. It is less than
one percent of men below the age of 30 have but increases to eight percent in
men over the age of 70. In case of leukoplakia buccal mucosa, alveolar mucosa
and lower lip are the most common sites. Lesions in the floor of mouth, lateral
tongue and lower lip are most likely to show dysplastic or malignant changes
and it is found in only 5% to 25% of biopsy samples of leukoplakia [2].
In the present
case with the use of diode laser, the patient experienced no deep tissue damage
and wound contraction. However, advantages of scalpel are distinct over the
laser i.e., low cost, and positive tactile feedback. Scalpel incisions heal
more rapidly than those made by lasers [6]. The histopathological marginal
clearance is better appreciated in scalpel excisions, but in cases of diode
lasers it is necessary to keep at least 2mm additional margin when excision is
planned as the tissues get charred closer to the lesion. Also, the thermal side
effects of the laser can further be controlled and reduced by altering the use
of power, pulse duration and pulse repetition rate. However, scalpel surgery
usually causes bleeding complications in leukoplakia cases, particularly when
excising from the floor of the mouth, dorsum of tongue, and the corners of the
mouth. Thick post-surgical scar tissue may be formed after healing. Grafting
procedures may be necessary for large lesion after surgery [7].
Re-epithelialization following laser surgery
is achieved with minimal wound contraction. Due to its high temperature, the
diode laser beam results in a sterile and non-contaminated wound. Lasers
produce a sterile surgical field based on instant vaporization of tissue and
adjacent vascular and lymphatic sealing. Furthermore, it helps in preventing
the seeding of the dysplastic cells in adjacent soft tissue areas [8].
However, some disadvantages of using laser on soft
tissue lesions usually include a prolonged healing time due to sealing of blood
and lymphatic vessels. The expense of laser systems and the relatively longer
rehabilitation period of treated areas seem to be the main disadvantages of the
laser procedures. As with all pre-malignancies, operating protocol must be
followed [9].
Leukoplakia is a potentially malignant lesion;
therefore, early diagnosis and treatment should be effectively carried out.
Dentists play an important role in both the education of patients about the
harmful effects of tobacco and chewing arecanut and in the early diagnosis of
high-risk oral leukoplakia and cancerous lesions. For treating oral leukoplakia
diode lasers proven to be an effective and less painful procedure. The future
of laser use in dentistry has exciting potential and should be studied through
scientifically based research.