Laser Biopsy, Decontamination, and Hemostasis: A Case Report

I am a laser dentist. I purchased the first laser for my practice in 1999. The use of dental lasers has changed how I approach the everyday care of my patients. This article will demonstrate some techniques that can be utilized to benefit both your patients and your practice.

DENTAL LASERS: A BRIEF BACKGROUND

Dental lasers have evolved in their 18 years of existence. Recent advances in technology have made the laser’s use highly successful in performing numerous dental procedures. Dentistry now has lasers and techniques to treat periodontal disease in a minimally invasive way, and other lasers to remove caries and prepare teeth for bonded restorations. Numerous dental procedures from surgical to cosmetic are performed using lasers.
Dental lasers work utilizing a beam of light which is amplified light energy. The energy is produced in the laser’s resonator, directed into a fiber-optic system, moves to the tip of the laser handpiece, then is placed precisely onto the biologic tissue, creating a thermal interaction. All this is done at the speed of light. Different lasers operate at specific wavelengths of light and have different effects on soft tissue, tooth, bone, and caries. The FDA has approved the use of lasers for both children and adults, and in the hands of trained clinicians, lasers are as safe as any other dental instrument.
Benefits from laser dental surgery include less bleeding, less swelling, no cross contamination, less use of antibiotics, increased comfort during recovery, no sutures or scalpels, no post-surgical packing materials, and decreased treatment duration. The laser’s use in dental treatment allows for comparable end results to more traditional and conventional therapies. Successful results in dentistry are possible using different methods. Laser surgery is just one of these.
The following simple case demonstrates the use of a soft-tissue laser utilizing principles from laser periodontal therapy1 to excise and biopsy tissue, decontaminate the wound, and to establish hemostasis.

CASE REPORT

Figure 1. Thirty days following extraction of tooth No. 29.

Figure 2. Extraction site immediately after biopsy and laser hemostasis.

Figure 3. Healing at 2 weeks postoperatively.

Figure 4. Six months post-extraction.

A 65-year-old male presented with a cystic growth 30 days following the extraction of tooth No. 29 (Figure 1). The patient was deemed to be in good health. He stated that he “had not seen a doctor in years” and was not currently taking any medications. He had stopped smoking 10 years ago.
Five weeks before, at an examination appointment, tooth No. 29 was found fractured near the gingiva with heavy calculus deposits. The tooth had been deemed unrestorable. One week later, the patient was anesthetized, tooth No. 29 was extracted, and laser hemostasis was utilized.2
My procedure following all extracted permanent teeth is to use a pulsed, Free Running Nd:YAG Laser (PerioLase MVP-7 TruePulse [Millennium Dental Technologies]), with a 1,064 nm wavelength at a wide pulse width to establish a stable thermal clot.3,4 At the same time, the bactericidal effect of the Nd:YAG laser treats any infection that is present.5 This clot formation allows patients to leave the operatory without any bleeding and no gauze in their mouths. In addition, there are no patient restrictions to eating, drinking, and oral hygiene. Therefore, I do not have the management problems that I had before using lasers. I no longer receive after-hour phone calls concerning post-extraction bleeding, or alveolar oste-itis. Healing is also rapid following these laser-assisted extractions.
Note that a particular laser wavelength 1,064 nm (Nd:YAG) and specific laser parameters are being used for this hemostasis technique. Be aware that laser physics does not allow substitution of diode, Erbium, or CO2 lasers in this safe, reproducible hemostasis technique. An excisional biopsy could be done using any of these lasers and wavelengths. I routinely use other dental lasers, but each laser has its designed uses and limitations.
The site was observed at 2 weeks post-surgery and exhibited slow but normal healing. It had become a food trap. The site was lavaged and the patient was placed on a daily oxygenating rinse. If the site did not continue to heal, the patient was instructed to return for curettage of the extraction site to restart the wound healing with new clot formation. It would also allow for laser decontamination and hemostasis.
Three weeks later, the patient presented for an emergency appointment during normal office hours. The patient had a painless, rapidly growing, fluid-filled cystic lesion. The differential diagnosis was either a granuloma caused by calculus, or a necrotic bone fragment within the wound site. The treatment plan was to perform an immediate excisional biopsy, curetting out the involved area. This procedure would be followed by lasing to decontaminate the biopsy site, while at the same time establishing hemostasis.
One carpule of 3% Mepivacaine (without a vasoconstrictor) local anesthetic was administered. The lesion was then excised with the laser. Laser parameters were 3.6 Watts 50 Hertz pulse width at 150 µsec, total joules equaled 160. Next the biopsy site was debrided using a surgical curette (No. 10 Miller Surgical Curette [Hu-Friedy]). Blood was allowed to pool in the site and then hemostasis was established using the laser set at parameters of 3.6 W 20 Hz pulse width 650 µsec. The free-running pulsed laser uses a 360-µm contact fiber tip. The fiber was placed to the depth of the extraction site and fired. The fiber was gradually moved coronally, continuously firing the laser. Observation showed a color change in the blood from crimson to reddish-brown with clot formation. Exposure time was 30 seconds, total 120 joules. Bacterial decontamination was accomplished and a stable thermal clot had been formed (Figure 2). Finally the biopsied tissue was immersed in a 10% formalin solution and sent to the pathology lab for an examination and report.
The patient was instructed to return 2 weeks after the biopsy for a postoperative evaluation. The site was well healed (Figure 3) and the patient reported no pain following the procedure or during the healing process. The patient had not taken any postoperative medications.
The following day (15 days postoperatively), the biopsy report arrived from the pathology lab. The definitive diagnosis was actinomycosis of the right posterior mandible. The pathology lab’s recommendation was for a regimen of Penicillin VK (Penicillin V Potassium).

DISCUSSION

In my 10 years of laser use, I have only had a handful of postextraction complications. This was one of those cases. Actinomycosis is primarily caused by the bacterium Actinomyces isrealii. Different species of Actinomyces (normally present in the mouth), as well as other bacteria, are also usually present. For this disease to occur, an injury to the mucous membrane and devitalized tissue needs to be present. This allows for the invasion of bacteria and the resulting disease. A recent history of a tooth extraction, or trauma to the mouth, can be instigating events. Risk factors include poor oral hygiene, dental caries, and periodontal disease. Occurrence is 3-to-1, male to female. The body’s reaction tends to be granulomatous or suppurative in Actinomycosis of the teeth. This often presents as a painful local swelling or a mass that forms. A definitive clinical diagnosis is difficult to make, surgery is needed to both diagnose and treat Actinomycosis.6
In this case, 2 weeks after laser surgery, the gingival tissue already showed closure and healing had occurred. There was no evidence of inflammation in the surgical area. The tissue changes, as seen from Figure 1 to Figure 3, occurred in just 14 days. Only less than 400 total joules of laser energy at the biopsy procedure date were used for therapy, with no medications.

CONCLUSION

Results of this case (Figure 4) indicate that use of the Nd:YAG laser for extraction site decontamination and hemostasis can be used to promote controlled healing of the extraction site. This couple of minutes of laser therapy, once again demonstrated for me, the human body’s wonderful ability to heal itself if treated properly and given the chance. Laser therapy had destroyed the Actinomyces bacteria from this dental abscess, stimulated rapid healing, and allowed the patient to recover without need for antibiotic therapy.


References

  1. Yukna RA, Carr RL, Evans GH, et al. Histologic evaluation of an Nd:YAG laser-assisted new attachment procedure in humans. Int J Periodontics Restorative Dent. 2007;27:577-587.
  2. Manni JG. Dental Applications of Advanced Lasers. Clinical Applications. 1996;5:8-5:23.
  3. Cranska JP. Nd:YAG Laser Soft Tissue Therapy, Combined with Extraction and Crown and Bridge Therapy. Paper presented at: Academy of Laser Dentistry, Advanced Clinical Case Studies Certification; March 2001; Tucson AZ.
  4. Cranska JP. Laser-assisted extraction, immediate bonded splint and bridge procedure. Contemp Esthet Restorative Pract. 2006;10:5:50-51.
  5. Whitters CJ, MacFarlane TW, MacKenzie D, et al. The bactericidal activity of pulsed Nd-YAG laser radiation in vitro. Lasers in Medical Science. 1994;9:297-303.
  6. Stewart MG. Actinomycosis of the Head and Neck. Grand Rounds Archive, Baylor College of Medicine Website. http://www.bcm.edu/oto/grand/62991.html. Presented June 29, 1991. Accessed October 7, 2008.

Dr. Cranska practices full-time laser and family dentistry in Severna Park, Maryland. He has Advanced Proficiency Laser Certification from the Academy of Laser Dentistry, and Standard Proficiency and Training Certification from the Institute for Advanced Laser Dentistry (IALD).

Disclosure: Dr. Cranska has no financial interest in any laser company. However, he is compensated as a clinical consultant for presenting, lecturing, and training by the IALD and Millennium Dental Technologies.