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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 3  |  Page : 472-474
Treatment of oral submucous fibrosis with ErCr: YSGG laser


1 Department of Oral and Maxillofacial Surgery, Maulana Azad Institute of Dental Sciences, Uttar Pradesh, India
2 Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, Uttar Pradesh, India
3 Department of Periodontics, Maulana Azad Institute of Dental Sciences, Uttar Pradesh, India

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Date of Submission21-Aug-2010
Date of Decision13-Sep-2010
Date of Acceptance16-Oct-2010
Date of Web Publication3-Nov-2011
 

   Abstract 

Oral submucous fibrosis (OSMF) is one of the most poorly understood and unsatisfactorily treated diseases. Various medical and surgical treatments have been used but with limited benefits. However, with advent of lasers, oral surgeons are provided with new modality for treating OSMF. This case report highlights the pioneering effort in treating a moderate case of bilateral OSMF with Erbium Chromium Yttrium Scandium Gallium Garnet (ErCr:YSGG) laser showing promising result during follow-up.

Keywords: Erbium Chromium Yttrium Scandium Gallium Garnet, hydro-photonic process, laser, oral submucous fibrosis

How to cite this article:
Chaudhary Z, Verma M, Tandon S. Treatment of oral submucous fibrosis with ErCr: YSGG laser. Indian J Dent Res 2011;22:472-4

How to cite this URL:
Chaudhary Z, Verma M, Tandon S. Treatment of oral submucous fibrosis with ErCr: YSGG laser. Indian J Dent Res [serial online] 2011 [cited 2019 Sep 17];22:472-4. Available from: http://www.ijdr.in/text.asp?2011/22/3/472/87073
Oral submucous fibrosis (OSMF) is one of the most poorly understood and unsatisfactorily treated diseases with risk of malignant change in advanced cases of OSMF being 3 to 6%. [1] Various medical treatments have been used but with limited benefit. Surgery is indicated when mouth opening is severely limited to compel the patient to resort to a liquid diet. Measures such as forcing the mouth open and cutting the fibrotic bands result in further fibrosis and disability. Submucosal resection of fibrotic bands and replacement with split thickness skin graft, buccal fatpad, tongue flap, or naso-labial flap has been attempted. [2] However, retrospectively surgery seems to be a poor option.

With the advent of lasers, oral surgeons are provided with a new modality for treating OSMF. The Erbium Chromium Yttrium Scandium Gallium Garnet (ErCr:YSGG) laser has a wavelength of 2780 nm, which is well absorbed by water enabling it to be used on oral soft tissue without causing thermal damage. [3] This case report highlights possibly the first use of this cold laser for treating a moderate case of bilateral OSMF.


   Case Report Top


An 18-year-old male presented to the oral surgery department (OSD) with chief complaint of limited mouth opening. Questioning revealed that he was in the habit of chewing tobacco since the last five years, with his symptoms starting two years ago and increasing progressively. He also complained of severe burning sensation in the oral cavity while eating spicy food. On examination, the inter-incisal opening was 22 mm [Figure 1], the oral mucosa was blanched in appearance, and fibrous bands were palpable bilaterally posteriorly. An incisional biopsy was performed that confirmed the diagnosis of OSMF. The patient did not reveal any other positive finding on history or examination. He had been on medical treatment with oral lycopene and local triamcinolone ointment, but no appreciable improvement was noticed by the patient even after one year of uninterrupted therapy.
Figure 1: Extra oral photograph showing pre-operative mouth opening

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A decision was made to surgically enhance the mouth opening with the use of ErCr:YSGG laser. Fibrotic bands in the region of pterygo-mandibular raphe, and faucial pillars were identified by light palpation, and under local anesthesia, a release was done with ErCr:YSGG laser at a power of 1.5 watts, water 10%, and air 13%, using a sapphire tip in non-contact mode, starting posteriorly at the level of the occlusal plane [Figure 2]. Primary closure was not done for the resultant defect, which was allowed to epithelise on its own. An inter-incisal Gap (IIG) of 35 mm was achieved intraoperatively [Figure 3]. Post operatively, the patient was advised jaw stretching exercise with a wooden spatula 6 to 7 times daily. A long-term course of antioxidants was also prescribed. Mouth opening increased to 25 mm on first post operative day but gradually increased to 40 mm within the next 15 days. Patient was followed-up for six month to assess recurrence of trismus, response to treatment, and relapse. However, none was seen [Figure 4].
Figure 2: Intra oral photograph showing laser fibrotomy

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Figure 3: Extra oral photograph showing immediate post operative
mouth opening


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Figure 4: Extra oral photograph showing 6th month post operatively

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   Discussion Top


OSMF is a chronic disease of the oral cavity commonly found in patients in the Asian subcontinent. In the pathogenesis of OSMF, a multi-factorial mechanism is thought to be at work, including areca nut chewing, ingestion of spicy red pepper, nutritional deficiency including vitamins and trace elements, hypersensitivity to various dietary constituents, and genetic and immunological susceptibility. [4] The signs and symptoms depend on progression of the lesion and on the number of affected sites. Characteristically, it presents with burning sensation in the oral cavity, blanching and stiffening of the oral and oropharyngeal mucosa, and trismus. The thick, inextensile, vertical fibrous bands, which appear in the cheek and faucial pillars, go on to encircle the lips, thereby narrowing the oral aperture. This not only causes disfiguring, but also results in limitation to accessing the oral cavity, leading eventually to malnutrition and poor oral hygiene. [4] Histopathology findings are the mainstay of diagnosis at present. The principal findings are decreased vascularity in the collagenous submucosa; mild to moderate chronic inflammation; epithelial changes consisting of atrophy and a variable degree of dysplasia; and varying degree of atrophy in the neighboring striated muscle fibers. [5] The different treatment strategies include local injections of placental extracts and hyaluronidase, supplemented with oral vitamins and anti-oxidants. Surgical options are employed when mouth opening is severely limited. These surgeries are performed under general anesthesia (GA) and are associated with the added risk of managing a difficult airway, apart from the usual risks associated with GA. Unfortunately, limited success has been seen with these procedures.

One of the latest revolutions in the field of medicine and dentistry has been the advent of lasers. Dental lasers provide an easy and comfortable option of keeping the procedures efficacious as well as minimally invasive. The quicker and uneventful healing after laser therapy adds to patient satisfaction. When tissues interact with laser, the effect is influenced by the emission wavelength, tissue optical properties, time of exposure, energy used, and absorption of the laser energy into the tissues. The absorptive effect determines how the target tissue's atoms and molecules convert laser light energy into heat, chemical, acoustic, or non-laser light energy. Thus, the amount of laser energy needed to produce the desired results varies depending on the tissue involved, and also the wavelength used. [6] In this case, the ErCr:YSGG (waterlase C-100) laser was used to release the fibrotic bands of OSMF that were causing limited mouth opening. An ErCr:YSGG laser works on 2780 μm wavelength, which has a high affinity for water and hydroxyapatite. It works on "hydro-photonic process" in which the laser energy from the ErCr:YSGG is able to interact with water droplets at tissue to create water molecule excitation. This, in turn, causes water droplet micro-expansion and propulsion that gives clean and precise hard-tissue cut. [7] The uniqueness of this system lies in the presence of air/ water spray, which has dual role to assist in the cutting as well as serving as coolant to keep the surface temperature low, thus eliminating any detrimental thermal side effect. [3],[8]

On soft tissue, the Er,Cr:YSGG laser works in a different manner, typically utilizing a small amount of water and air as coolant. The cutting of the tissue is the result of direct laser energy seeking out the abundance of water molecules contained in the soft tissue. The photo-thermal action results in disruption of the tissue, using sufficient deposition of heat to vaporize the tissue. [9] It has been shown that the ErCr: YSGG laser energy is selectively absorbed in the target tissue and may result in either a direct tissue cut (cold cut) or vaporization of the water within a cell, causing rupture (thermal cut), a process known as thermal-mechanical tissue ablation. [7] The thermal-mechanical tissue ablation limits the amount of collagen damage to as little as 5 μm (approximately 2 cell widths), leaving the extracellular collagen matrix unaffected. There is also reportedly less histamine release in tissues treated with laser, which accounts for the minimal post operative pain and inflammation. Furthermore, there is virtually no scarring and minimal tissue shrinkage on crestal or sulcular incisions. Reports indicate that there is 0.5 mm of tissue shrinkage with a laser, compared to 3 mm with a Bard-Parker blade. [10] The procedure may or may not be as fast, but the post operative benefits for the patient are immense.

The overall benefits of laser surgery include a relatively bloodless operative field and thus excellent visibility, reduced need for local anaesthesia, less chances of bacterial infection, reduced mechanical tissue trauma, fewer sutures, quicker healing, and reduced post operative edema, scarring and tissue shrinkage. At the same time, the possible complications in laser surgery can be excessive or collateral tissue damage due to misdirected usage.


   Conclusion Top


While dental lasers are still in their infancy, there is no doubt that the profession has started accepting them as an alternative to traditional therapies. ErCr:YSGG laser has utility in both hard and soft tissue procedures as the hydro-photonic process allows it to out-perform other conventional modalities in many ways. Common soft and hard tissue procedures done with lasers include, but are not limited to, maxillary and mandibular frenectomies, lingual frenectomy, operculectomy, gingivectomy around orthodontic brackets, fibroma removal, treatment of dilantin hyperplasia, removal of mucocele, uncovering tissue around implants, treatment of aphthous ulcers, cosmetic tissue recontouring, cavity preparations, apicoectomy etc. [6] All in all, laser surgery is effective and safe. This case highlights the use of ErCr:YSGG laser as an innovative and precise method for treatment of OSMF. However, we need a larger study with long term follow-up in similar cases before applying this modality for treatment in routine clinical practice.


   Acknowledgment Top


I want to acknowledge Dr. Manish Naithani and Dr. Pankaj Sharma for their invaluable support in the work.

 
   References Top

1.Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-96.   Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Mehrotra D, Pradhan R, Gupta S. Retrospective comparison of surgical treatment modalities in 100 patients with oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:1-10.  Back to cited text no. 2
    
3.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;20:245-50.  Back to cited text no. 3
[PUBMED]    
4.Auluck A, Rosin MP, Zhang L, Sumanth KN. Oral submucous fibrosis, a clinically benign but potentially malignant disease: Report of 3 cases and review of the literature. J Can Dent Assoc 2008:;74:735-40.   Back to cited text no. 4
    
5.Murti PR, Bhonsle RB, Gupta PC, Daftary DK, Pindborg JJ, Mehta FS. Etiology of oral submucous fibrosis with special reference to the role of areca nut chewing. J Oral Pathol Med 1995;24:145-52.  Back to cited text no. 5
[PUBMED]    
6.Catone GA, Ailing CC. Laser Applications in Oral and Maxillofacial Surgery. 1 st ed. 1997.  Back to cited text no. 6
    
7.Kimmel AI, Rizoiu IM, Eversole LR. Phase doppler particles analysis of laser energy exploding water droplets. Presented at: Athens, Greece: International Laser Congress: Lasers at the Dawn of the Third Millennium; 1996.   Back to cited text no. 7
    
8.Eversole LR, Rizoiu IM. Preliminary investigations on the utility of an erbium, chromium: YSGG laser. J Calif Dent Assoc 1995;23:41-7.  Back to cited text no. 8
    
9.Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium yttrium, scandium, gallium, garnet laser on mucocutaneous soft tissues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:386-95.  Back to cited text no. 9
[PUBMED]    
10.Pumphrey DW. Creating the esthetic anterior implant. Lecture presented at Hinman Dental Meeting. 2004.  Back to cited text no. 10
    

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Correspondence Address:
Zainab Chaudhary
Department of Oral and Maxillofacial Surgery, Maulana Azad Institute of Dental Sciences, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.87073

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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    Abstract
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