Original Article Is the 810‑nm diode laser the best choice in oral soft tissue therapy? Nihat Akbulut1, E. Sebnem Kursun2, M. Kemal Tumer3, Kivanc Kamburoglu2, Ugur Gulsen4 1Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Gaziosmanpasa, Tokat, Turkiye, 2Departments of Oral and Maxillofacial Radiology, Faculty of Dentistry, University of Ankara, Ankara, Turkiye, 3Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Gazi, Ankara, Turkiye, Correspondence: Dr. Nihat Akbulut 4Department of Oral and Maxillofacial Surgery, Faculty Email: [email protected] of Dentistry, University of Ankara, Ankara, Turkiye ABSTRACT Objective: To evaluate the safety and efficacy of an 810‑nm diode laser for treatment of benign oral soft tissue lesions. Materials and Methods: Treatment with the 810‑nm diode laser was applied to a group of eighteen patients with pathological frenulum and epulis fissuratum; five patients with oral lichen planus, oral leukoplakia, and mucous membrane pemphigoid; and four patients with pyogenic granuloma. Results: Although the conventional surgery wound heals in a fairly short time, in the present study, the simple oral soft tissue lesions healed within two weeks, the white and vesiculobullous lesions healed completely within six weeks, and the pyogenic granuloma lesions healed within four weeks. Any complication was treated by using the 810‑nm diode laser. Conclusions: Patient acceptance and satisfaction, without compromising health and function, have been found to be of a high degree in this present study. Thus, we can say that the use of the 810‑nm diode laser may indeed be the best choice in oral soft tissue surgery. Key words: Diode laser, oral soft tissue lesions, oral surgery, white lesions INTRODUCTION procedures because their specific wavelength (810‑980 nm) is absorbed not only by water (although Innovative technologies, such as diode lasers, have less so than the carbon dioxide laser wavelength), but provided considerable benefit to dental patients and also by other chromophores, such as melanin, and in dentists.[1,2] In addition, the role of lasers in dentistry is particular, oxyhemoglobin. Moreover, the exclusive well‑established in both the conservative and surgical use of this laser by contact or at an extremely close management of oral diseases.[2‑4] distance avoids damage, due to ‘beam escape,’ in an open field, which makes it much safer than other laser The diode laser is a semiconductor that uses solid‑state sources. In addition, diode lasers have the ability to elements, such as gallium, arsenide, aluminum, and cut the tissue to perform coagulation and hemostasis, indium, to change electrical energy into light energy. and have a higher tissue ablation capacity and enough The light energy from the diode is greatly absorbed bleeding hemostatic properties compared to most by the soft tissue and poorly absorbed by the teeth laser systems.[1,4,6] and bones.[5] Clinical experience suggests some advantages of Diode lasers are useful for oral soft tissue surgical the laser over scalpel surgical procedures on oral How to cite this article: Akbulut N, Kursun ES, Tumer MK, Kamburoglu K, Gulsen U. Is the 810-nm diode laser the best choice in oral soft tissue therapy?. Eur J Dent 2013;7:207-11. Copyright © 2013 Dental Investigations Society. DOI: 10.4103/1305-7456.110174 European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 207 Akbulut, et al.: Is the 810‑nm diode laser the best choice in oral surgery? tissues. These advantages include greater precision, a and on an outpatient basis. Both the patients and the relatively bloodless surgical and postsurgical course, surgeons wore protective glasses. sterilization of the surgical area, minimal swelling and scarring, coagulation, vaporization, cutting, minimal Treatment was carried out using 12 different settings or no suturing, and less or no postsurgical pain.[7,8] of the MedArt 426 Diode Laser System (Asah Medico A/S, Hvidovre, Denmark). The laser output Studies have shown that laser surgery is widely power ranged from 0, 5‑30 W, the pulse rate from used for oral lesions, such as, simple soft tissue 10‑1000 msec in a pulsed mode, and the frequency surgery (frenectomy, epulis, gingival contouring from 0, 3‑100 Hz. The laser could also be operated plasty, etc.),[1‑3,5,7] vascular lesions (hemangiomas, in a continous wave (cw) mode, as was done during telangiectasias, etc.),[4,6] pigmented lesions (gingival the procedure. The target beam was generated by an pigmentations),[1] white oral lesions (oral leukoplakia, aluminum, arsenide, and gallium laser (810 – nm). The oral lichen planus, etc.),[9,10] and low‑level laser laser beam was delivered by ultrathin optical fibers therapy (LLLT) in vesiculobullous lesions (mucous of 400‑1000 µm, enabling it to be moved easily and membrane pemphigoid).[7] quickly during surgical procedures. The purpose of this study is to determine the efficacy Simple oral soft tissue surgery and safety of the 810‑nm diode laser for treatment of Eighteen patients (10 epulis fissuratum [Figure 1a] oral soft tissue lesions or diseases, and to answer the and eight labial frenectomy) were treated with the question of whether the 810‑nm diode laser is the best diode laser. The treatment was carried out by moving choice in oral soft tissue surgery. a slightly focused 810‑nm diode laser. The laser had an output power of 5‑10 W, high‑power continuous MATERIALS AND METHODS wavelength, and a spot size of 2 mm. The surgical operation was performed using the excision method under local anesthesia [Figure 1b]. A total of 27 patients who had different benign oral lesions were treated with the 810‑nm diode laser at the Treatment of oral white and vesiculobullous Oral and Maxillofacial Surgery Department, Faculty lesions of Dentistry, Ankara University, between the years Five patients with histologically proven disorders, 2009 and 2011. An informed written consent form including two with leukoplakia [Figure 2a], two with was obtained from all participating adults and from oral lichen planus [Figure 3a], and one with oral mucous parents or legal guardians for minors or incapacitated membrane pemphigoid, were selected for 810‑nm adults (19 females and eight males, 10 smokers and diode laser treatment. They had been treated with 17 nonsmokers, 21 to 72 years of age) in accordance different drugs (fluocinonide, triamcinolone, LLLT) with the Declaration of Helsinki. All patients had or a wait‑and‑see policy before the 810‑nm diode laser previously taken conventional medical treatment evaporation. All patients, who had had recurring lesions procedures (local corticosteroid, beta carotene, vitamin or bad results with their previous treatment options, E, fluocinonide, triamcinolone, LLLT, etc.) except the were prepared for laser surgery treatment. A defocused patients having epulis fissuratum or pathological 810‑nm diode laser was chosen for evaporation of frenulum. Unfortunately, the lesions in all patients the superficial mucosal lesions [Figure 2b, 3b]. The reoccurred. Therefore, the diode laser treatment was laser had an output power of 10‑15 W, high‑power selected as an alternative treatment option for these continuous wavelength and 2‑mm spot size. patients. Pyogenic granuloma The cases have been studied retrospectively. Patients Four patients with pyogenic granuloma, diagnosed with any systemic diseases were excluded from the study, and all operations were performed by the same surgical team. The diagnosis of all lesions or disorders was confirmed by histopathological examination, especially in a b c patients who suffered from white, vesiculobullous, Figure 1: (a) Preoperative view of the epulis fissuratum lesion of a and pyogenic granuloma lesions. All treatments were patient, (b) immediate postoperative view of the treated area, (c) view performed with the patients under local anesthesia of the treated area two weeks after diode laser intervention 208 European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 Akbulut, et al.: Is the 810‑nm diode laser the best choice in oral surgery? clinically, were treated with a diode laser, with an At the two‑week follow‑up, the simple oral soft tissue output power of 10‑15 W, high‑power continuous surgery patients had healed without scarring or any wavelength, and 2‑mm spot size. First, the lesions other complications, such as hemorrhage [Figure 1c]. were excised with a focused 810‑nm diode laser under local anesthesia and then the surgical material was At the six‑week follow‑up, the patients with oral white and vesiculobullous lesions had healed without sent for histopathological study. Immediately, the scarring [Figure 2c, 3c]. No charring or carbonization surgical field was evaporated with a defocused 810 nm occurred during the procedure [Figure 2b, 3b]. diode laser. The histopathological study confirmed Unfortunately, the patient with mucous membrane the clinical diagnosis. pemphigoid disorder had moderate bleeding intraoperatively and postoperatively, which was In all the 27 patients treated, the areas surrounding stopped by suturing the bleeding region. the treated tissue were cooled after the laser surgical procedure. All the patients were given suitable At the four‑week follow‑up, the patients with pyogenic postoperative care such as 0.2% chlorhexidine granuloma lesions had healed without scarring or any mouthwash, and paracetamol analgesics were other complications, such as hemorrhage. No charring prescribed. All patients were seen on a regular basis or carbonization occurred during the procedure. for follow‑up: At one, two, and six weeks, and two months after treatment. In all cases, there were no incidents of infection in the days following the procedure. No sutures were RESULTS required except for one patient. All the patients were satisfied with the treatment and the results obtained. The study included 27 patients treated with 810‑nm They were comfortable and experienced no pain, diode laser settings [Table 1], including 10 with either intraoperatively or postoperatively. epulis fissuratum, eight with labial frenectomy, two with leukoplakia, two with oral lichen planus, one DISCUSSION with mucous membrane pemphigoid lesion, and four with pyogenic granuloma. In our study, we have evaluated the effects of the 810‑nm diode laser in the treatment of 27 patients with various benign oral soft tissue lesions. Diode, a b c a b c Figure 2: (a) Immediate preoperative view of the treated area of a Figure 3: (a) Preoperative view of a lichen planus lesion, (b) postoperative leukoplakia patient, (b) immediate postoperative view of the treated view of the treated lesion, (c) view of the healed lesion after six weeks area, (c) view of the treated area six weeks after diode laser intervention laser treatment Table 1: Descriptive information on the 810-nm diode laser treatment Measure Number of Application Power Diagnosis Treatment option Bleeding Healing patients from output (W) (Excision/Evaporation) (Yes/No) time (week) Simple oral soft 18 Focused mode 5-10 Clinically Excision No 2 tissue surgery patients Oral white and 5 Defocused 10-15 Clinical and Evaporation No, except 6 vesiculobullous mode histopathological one patient lesion treatment confirmation Pyogenic 4 Focused and 10-15 Clinical and Excision and No 4 granuloma defocused histopathological evaporation patients mode confirmation European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 209 Akbulut, et al.: Is the 810‑nm diode laser the best choice in oral surgery? neodymium, erbium, and CO2 lasers are approved therapy mentioned above. When we did not obtain a by the Food and Drug Administration (FDA) for definite result from this treatment option, we decided use in oral surgery.[11] The use of lasers in a variety to apply the 810‑nm diode laser to our patients in of surgical procedures has been well documented. order to obtain acceptable results. Diode lasers present a solid semiconductor as an active medium, by associating aluminum, gallium, Initially, clinicians treated oral leukoplakia and arsenate (with wavelengths varying between with vitamin A, vitamin E, and beta‑carotene. 800 and 980 nm) in the visible and invisible range However, because of the toxicity of vitamin A of near infrared waves. As its wavelength is poorly and the unsatisfactory response to vitamin E and absorbed by the hard dental tissue, the diode laser is beta‑carotene, the use of these drugs for the treatment safe and well indicated for soft oral tissue surgeries of oral leukoplakia has been discontinued.[9,17] The in regions near the dental structures and for cutting, other treatment modalities for oral leukoplakia are vaporization, curettage, blood coagulation, and scalpel excision or electrocautery and cryosurgery, hemostasis in the oral region.[11,12] Some authors, for which there is a recurrence rate of approximately such as Goharkhay et al.[7] and Gontijo et al.,[11] have 33%.[9,18] Studies[9,19] on the clinical usefulness of laser reported success in the treatment of oral soft tissue surgery in oral leukoplakia have shown that the laser lesions using a diode laser. surgery prevents not only recurrence and malignant transformation, but also postoperative dysfunction. In our study, an 810‑nm diode laser was used surgically In our study, we used 810‑nm high‑power laser for safe elimination of soft oral tissue lesions; no surgery to treat these lesions and obtained excellent complications occurred in the surrounding soft tissue results. or hard tissue. We adopted the 810‑nm diode laser for our patients due to its availability, the convenience of its Mucous membrane pemphigoid (MMP) is a rare application, the ability for large areas to be treated in a chronic disorder of the mucosal tissue manifested single application, and the possibility of precise control largely by vesiculobullous lesions of the oral cavity and of laser fluence in all areas of the mouth. This pattern, eyes.[20,21] Additionally, MMP most often involves the especially of producing precise surgical incisions, was oral cavity followed by the conjunctiva and genitalia. in accordance with those observed by Genovese et al.[4] The clinical manifestations of mucous membrane and D’Arcangelo et al.[13] Alongside all this, Aras et al.[5] pemphigoid are varied, but the oral and conjunctival compared diode laser with the Er: YAG laser revealed mucosae are most frequently involved. The condition that Er: YAG laser was more comfortable because of the is also commonly termed as cicatricial pemphigoid, lower local‑anesthesia requirement. but the term cicatricial later excluded patients without scarring.[20] Conjunctival involvement occurs in up Soft tissue procedures cause postsurgical pain and to 75% of the patients.[21] However, one patient in discomfort when chewing, eating, breathing, and our study had no lesion with conjunctival mucosa speaking.[5] Aras et al.[5] has reported that on evaluating involvement. Immunosuppressive therapy is the the patients for pain during the first three hours mainstay treatment for MMP. Surgery has a diagnostic after surgery, those in the Er: YAG laser group had approach to the lesions, such as, stenosis and airway a higher degree of pain than those in the diode laser group. Kara[14] has suggested that Ne: YAG laser obstruction. frenulectomy provides better patient perception of Whiteside et al.[21] treated supraglottic airway stenosis success than that seen with conventional surgery. with the CO laser and had good results. First, our However, in our study, we have not encountered any 2 patient with an MMP lesion on the left side of her reports of pain from the patients. tongue had taken conventional therapy, such as, According to the literature, the mainstay treatment topical corticosteroids, tetramycin, LLLT, and some for oral lichen planus is topical steroids. In oral lichen immunosuppressive adjuvants; unfortunately, these planus cases where topical approaches have failed, did not yield good results. Thus, we chose diode systemic corticosteroids can be considered. Several laser excision as the treatment option. We had a studies[10,15,16] have shown good results with this moderate bleeding complication intraoperatively treatment, but side effects have also been reported. and postoperatively, but the lesion healed completely In our study the white lesions, especially oral lichen within six weeks. The patient was satisfied with this planus, were initially treated with the conventional treatment option. 210 European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 Akbulut, et al.: Is the 810‑nm diode laser the best choice in oral surgery? Pyogenic granuloma is a frequently diagnosed, 10. van der Hem PS, Egges M, van der Wal JE, Roodenburg JL. CO 2 laser evaporation of oral lichen planus. Int J Oral Maxillofac Surg benign vascular lesion. The possible treatment 2008;37:630-3. methods are excision, curettage, cryotherapy, 11. Gontijo I, Navarro RS, Haypek P, Ciamponi AL, Haddad AE. The chemical and electric cauterization, and the use of applications of diode and Er: YAG lasers in labial frenectomy in infant patients. J Dent Child 2005;72:10-5. lasers.[22‑26] Surgical excision or electrocoagulation 12. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial is considered the standard treatment for pyogenic surgery. Dent Clin North Am 2004;48:861-88. 13. D’Arcangelo C, Di Nardo Di Maio F, Prosperi GD, Conte E, Baldi M, granuloma. However, because of scarring, excision Caputi S. A preliminary study of healing of diode laser versus scalpel is a suboptimal form of therapy; bleeding can also incisions in rat oral tissue: A comparison of clinical, histological, and complicate the operation process, especially in huge immunohistochemical results. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:764-73. granulomas or if the excision is close to the lesion. 14. Kara C. Evaluation of patient perceptions of frenectomy: A comparison Laser excision may be the ideal treatment option for of Nd: YAG laser and conventional techniques. Photomed Laser Surg 2008;26:147-52. these type of lesions.[23,24] For our pyogenic granuloma 15. Carbone M, Gross E, Carozzo M, Castellano S, Conrotto D, Brocoletti R, patients, the selected treatment option of 810‑nm et al. Systemic and topical corticosteroids treatment of oral lichen diode laser excision resulted in completely healed planus: A comparative study with long-term follow up. J Oral Pathol Med 2003;32:323-9. lesions. 16. Buajeeb W, Pobrurksa C, Kraiva-Phan P. Efficacy of fluocinolone acetnide gel in the treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol 2000:89:42-45. CONCLUSION 17. Epstein JB, Gorsky M. Topical application of vitamin A to oral leukoplakia: A clinical case series. Cancer 2000;86:921-7. The use of lasers, especially diode lasers, in general 18. Saito T, Sugiura C, Hirai A, Notani K, Totsuka Y, Shindoh M, et al. Development of squamous cell carcinoma from pre-existent oral dentistry is now an accepted treatment aid, with a leukoplakia: With respect to treatment modality. Int J Oral Maxillofac wide range of applications in oral soft tissue surgery. Surg 2001;30:49-53. 19. Ishi J, Fujita K, Munemoto S, Komori T. Management of oral We also see that the use of the 810‑nm diode laser as leukoplakia by laser surgery: Relation between recurrence and the treatment of choice for oral soft tissue therapy is malignant transformation and clinicopathological features. J Clin reliable because we obtained acceptable healing of the Laser Med Surg 2004;22:27-33. 20. Whiteside OJ, Martinez Devesa P, Ali I, Capper JW. Mucous membrane lesions with minimal adverse effect. Thus, in oral soft pemphigoid; nasal and laryngeal manifestations. J Laryngol Otol tissue surgery, the use of 810‑nm diode lasers may be 2003;117:885-8. 21. Silverman S Jr, Gorsky M, Lozada-Nur F, Liu A. Oral mucous the best choice. membrane pemphigoid. A study of sixty-five patients. Oral Surg Oral Med Oral Pathol 1986;61:233-7. REFERENCES 22. Chan LS, Ahmed AR, Anhalt GJ, Bernauer W, Cooper KD, Elder MJ, et al. The first international consensus on mucous membrane pemphigoid: Definition, diagnostic criteria, pathogenic factors, 1. Desiate A, Cantore S, Tullo D, Profeta G, Grassi FR, Ballini A. 980 nm medical treatment, and prognostic indicators. Arch Dermatol diode lasers in oral and facial practice: Current state of the science 2000;138:370-9. and art. Int J Med Sci 2009;6:358-64. 23. Raulin C, Greve B, Hammes S. The combined continuous-wave/ 2. Kafas P, Stavrianos C, Jerjes W, Upile T, Vourvachis M, Theodoridis M, pulsed carbon dioxide laser for treatment of pyogenic granuloma. et al. Upper-lip laser frenectomy without infiltrated anaesthesia in a Arch Dermatol 2002;138:33-7. paediatric patient: A case report. Cases J 2009;2:7138. 24. Powell JL, Bailey CL, Coopland AT, Otis CN, Frank JL, Meyer I. 3. Ishikawa I, Aoki A, Takasaki AA. Clinical application of erbium: YAG Nd: YAG laser excision of giant gingival pyogenic granuloma of laser in periodontology. J Int Acad Periodontol 2008;10:22-30. pregnancy. Lasers Surg Med 1994;14:178-183. 4. Genovese WJ, dos Santos MT, Faloppa F, de Souza Merli LA. The use 25. Glass AT, Milgraum S. Flashlamp-pumped pulsed dye laser treatment of surgical diode laser in oral hemangioma: A case report. Photomed for pyogenic granuloma. Cutis 1992;49:351-353. Laser Surg 2010;28:147-51. 26. Goldberg DJ, Sciales CW. Pyogenic granuloma in children: Treatment 5. Aras MH, Göregen M, Güngörmüş M, Akgül HM. Comparison of with the flashlamp-pumped pulsed dye laser. J Dermatol Surg Oncol diode laser and Er: YAG lasers in the treatment of ankyloglossia. 1991;17:960-962. Photomed Laser Surg 2010;28:173-7. 6. Saetti R, Silvestrini M, Cutrone C, Narne S. Treatment of congenital subglottic hemangiomas: Our experience compared with reports in Access this article online the literature. Arch Otolaryngol Head Neck Surg 2008;134:848-51. 7. Goharkhay K, Moritz A, Wilder-Smith P, Schoop U, Kluger W, Quick Response Code: Jakolitsch S, et al. Effects on oral soft tissue produced by a diode laser Website: www.eurjdent.com in vitro. Lasers Surg Med 1999;25:401-6. 8. Pick RM, Colvard MD. Current status of lasers in soft tissue dental surgery. J Periodontol 1993;64:589-602. 9. Vivek V, Jayasree RS, Balan A, Sreelatha KT, Gupta AK. Three-year Source of Support: Nil. follow-up of oral leukoplakia after neodymium: Yttrium aluminum Conflict of Interest: None declared garnet (Nd: YAG) laser surgery. Lasers Med Sci 2008;23:375-9. European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 211