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General

Introduction
Dental clinicians often encounter small lesions on the lips and areas bordering the lips that raise an important question: how far outside the oral cavity does the scope of dentistry extend? Where does the practice of dentistry coincide with the overall health of the patient in areas surrounding the oral cavity?
While a dentist should be properly trained and proficient in recognizing the potential serious lesions that can occur on the face and neck, most dentists do not feel comfortable removing more benign lesions on the lips, vermillion border or areas of the face bordering the oral cavity. This fear is compounded by the use of scalpels or instruments that generate and rely on heat (electrosurge, bipolar devices) to remove these lesions. These instruments can create excessive bleeding, swelling, requisite suturing and possible residual scarring to highly visible areas surrounding the oral cavity.
Because of these fears and conditions, it would be beneficial to clinician and patient alike if there were a highly predictable method to remove small lesions in the peri-oral regions with minimal bleeding, along with eliminating the need for sutures and no residual scaring. This would open a potential area of treatment that may have been neglected due to lack of referral or fear of unknown cosmetic results.
In recent months, the Er,Cr:YSGG laser device, which has been primarily used for both hard , and soft tissue in dental cases, has also been granted clearance by the U.S. Food and Drug Administration for use in dermatological applications , – which can expand its utility in a dental practice. This device represents an atraumatic, scalpel-less methodology for simple peri-oral lesions and other minor dermatological applications.
This article will present two clinical cases in which an Er,Cr:YSSG laser was used successfully to remove lesions surrounding the oral cavity. The first case involves removal of a mucocele located on the lower lip. The second case is the removal of a small nevus on the vermillion border of the lower lip. Both cases were accomplished with minimal bleeding, no placement of sutures, minimal post-operative discomfort and no residual scarring. Both cases were submitted for biopsy. As a side note, the importance of biopsy in somewhat benign appearing lesions can’t be stressed enough as we never can confidently identify lesions by clinical appearance alone.

Case 1 – Removal of a mucocele
A 9-year-old female presented with a round raised lesion measuring 3 to 4 mm in diameter. It was located on the mid-left lower lip. The lesion appeared to be filled with fluid but attempts at drainage were unsuccessful. The patient’s mother related a history of the lesion varying in size and stated it had been present for approximately 4 months. (Figure 1)

Clinical diagnosis: Mucocele (inflamed) fluid-filled minor salivary gland.

Er,Cr:YSGG laser treatment recommendations: Incise complete minor salivary gland with Er,Cr:YSGG laser (Waterlase, Biolase, Irvine, Calif., USA) utilizing topical anesthetic. The laser’s setting are 1.0 watts, 30hz, 9% water & 12% air. Procedure: First, perform a circumferential incision and separation of the lesion from the surrounding tissue to the base of duct (Figure 2).

Note that no sutures are necessary. The laser setting is changed to 0.5 watt, 30hz, no air and no water to create a “laser bandage” over the surgical site. Vitamin E gel was then placed over the site to stimulate healing.

Pathology report: Microscopic description: A fragment of oral mucosa is remarkable for focal parakeralosis and a rare lymphocyte within the epithelium. No dysplasia is identified. No salivary gland is identified. A PAS-D stain is negative for fungal organisms, however, if stain areas of the underlying stroma which is consistent within mucin. Within this area which is scanty and at the edge of the biopsy, there are a few neutrophils.

Pathologic diagnosis: Left lower lip, biopsy: oral mucosa with changes suggestive of mucocele. Mild parakeratosis consistent with irritation.
Post-operative treatment and instruction: Placement of vitamin E gel, 3-4 times daily over site. Also prescribed over-the-counter analgesics as needed for discomfort.

We contacted the patient’s mother the night of the treatment; she reported no adverse symptoms and minimal discomfort. Patient was seen at one-week follow-up appointment.(Figure 3)


Case 2 – Removal of small nevus
A 36-year-old male presented with a round, raised lesion on the vermillion border of the lower right lip. The lesion measured 3-4 mm in diameter. The patient was not sure how or when the lesion appeared. His chief complaint was that he periodically cut into the lesion while shaving causing pain and irritation. The patient had undergone a medical consult and was told by the practitioner that the lesion could be removed with a scalpel, requiring an elliptical shaped incision to remove the lesion and then placement of sutures to close the wound site. The patient declined treatment due to the high likelihood of scarring to a very visible area of the face (Figure 4).



Clinical diagnosis: Nevus

Laser treatment: Remove the nevus lesion with an Er,Cr:YSGG (2780nm) all-tissue laser . Laser settings: 1.25 watts, 30hz, 9% water, 12% air with .50cc 2% lidocaine, local infiltration, 1-100,000 epinephrine. User Er,Cr:YSGG laser to circumferentially incise and remove the lesion. No sutures are necessary (Figure 5).



laser’s settings are then changed to 0.5 watts, 30hz, no air and no water. This setting allows for a “laser bandage. “ Note that the “bandage” setting helps promote hemostasis and healing. Vitamin E gel was then placed over the surgical site.
Pathology report: Microscopic description: Sections show portions of hypertrophic skin with a vaguely papillomatous surface. There is hypergranulosis and hyperkeratosis with mounds of parakeratosis extending off of the papillary tips. There is no dysplasia or invasive component. Focally the cells show apparent viropathic effect, consistent with a verruca vulgaris. There is solar elastosis in the underlying dermis with scattered thin walled vessels. A distinctive area of fibrosis is not appreciated.
Pathologic diagnosis of skin biopsy: Benign keratosis consistent with verruca vulgaris.
Post-operative instruction: Patient was instructed to place vitamin E gel over surgical area 3-4 times daily, and use any over-the-counter analgesics as needed. We contacted the patient the evening of the treatment and he reported no complications and no need for analgesics. The patient was recalled for a two-week post-operative appointment (because he was unable to return for a one-week checkup) (Figure 6).


Conclusion
Both cases demonstrate the effectiveness of using an Er,Cr:YSGG all-tissue dental laser to safely and a traumatically remove small benign lesions from the facial areas bordering the oral cavity. The laser causes minimal bleeding, minimal discomfort and very little possibility of scarring. As dentists, we are the health care professionals most likely to encounter and diagnose these lesions. At that point, we can remove or make the decision to refer out to a specialist. However, with a device like the Er,Cr:YSGG laser available, dentists can choose to retain more of these simple soft-tissue procedures. As stated previously, if you do choose to remove any oral lesions, biopsy is a mandatory step in the process. This can demonstrate to your patients how you can help provide meaningful information and care to their whole body and health – especially in the vital area of face and neck.



References

Hadley J, Young DA, Eversole LR, Gornbein JA. A laser-powered hydrokinetic system for caries removal and cavity preparation. J Am Dent Assoc. 2000 Jun;131(6):777-85.
Wang X, Ishizaki NT, Suzuki N, Kimura Y, Matsumoto K. Morphological changes of bovine mandibular bone irradiated by Er,Cr:YSGG laser: an in vitro study. J Clin Laser Med Surg. 2002 Oct;20(5):245-50.

Eversole LR, Rizoiu IM. Preliminary investigations on the utility of an erbium, chromium YSGG laser. J Calif Dent Assoc. 1995 Dec;23(12):41-7.
Department of Health and Human Services. Laser surgical instrument for use in general and plastic surgery and in dermatology. Jan. 28, 2008. On file: K071734.
Biolase press release. Biolase Announces FDA 510(k) Clearance of Its Waterlase(R) MD Laser System for Dermatology. Newswire: February 7, 2008.

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