Review: laser soft tissue treatments for paediatric dental patients.
Abstract: BACKGROUND: Many soft tissue pathologies in children can be treated by paediatric dentists. New technologies such as laser surgery enable simpler treatments to be carried out than with conventional techniques. REVIEW: This paper reviews soft tissue lasers and discusses their use in paediatric patients. The laser is a good tool for soft tissue management in children and is well accepted by patients and their relatives. Laser treatment involves a reduction in the use of medication (anaesthetics, analgesics and antibiotics) and in intra-operative and post-operative bleeding. It eliminates the need sutures and produces faster wound healing and less scarring. CONCLUSION: It is essential to have a good knowledge of laser operation and of which type of laser is most appropriate for each lesion.

Key words: Laser paediatric dentistry, erbium lasers, C[O.sub.2] lasers, diode lasers, laser soft tissue treatments.
Article Type: Clinical report
Subject: Cryosurgery (Health aspects)
Lasers in surgery (Health aspects)
Soft tissue injuries (Care and treatment)
Tooth diseases (Care and treatment)
Authors: Boj, J.R.
Poirier, C.
Hernandez, M.
Espasa, E.
Espanya, A.
Pub Date: 04/01/2011
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2011 Source Volume: 12 Source Issue: 2
Geographic: Geographic Scope: Spain Geographic Code: 4EUSP Spain
Accession Number: 277106751
Full Text: Introduction

Many benign pathologies or oral anomalies that appear in children's soft tissues can be treated by dentists. Conventional treatment of these pathologies involves the use of the cold knife, electrocautery or cryosurgery (using a gas expansion system or a cotton bud soaked in liquid nitrogen) [Ishida and Ramos-Silva, 1998]. Laser treatment can be added as an alternative or complement to conventional methods [Gontijo et al., 2005]. There is extensive literature on soft tissue management using lasers [Miserendino and Pick, 1995; Bradley, 1997; Strauss, 2000; Stabholz et al., 2003; Kotlow, 2004; Strauss and Fallon, 2004; Brugnera et al., 2006; Kato and Wijeyeweera, 2007; Kotlow, 2011]. Some oral lesions that are susceptible to laser treatment are:

* fraenectomy: maxillary labial [Gontijo et al., 2005], lingual [Verco, 2007],

* vascular lesions: granulomatous hyperplasia [Tamarit et al., 2005], pyogenic granuloma [Boj et al., 2006a], haemangiomas and telangiectatic epulis [Vesnaver and Dovsak, 2006],

* gingival hyperplasia: due to appliances, collateral effects in anti-epileptic drug treatment or bad hygiene [Fornaini et al., 2007],

* periodontics: lasers can be used to disinfect the periodontal pocket (the peak power of a pulsed laser kills resistant subgingival bacteria); periodontal scaling and root planing with Nd:YAG lasers reduces bone and cement loss, improves the epithelial junction and eliminates periodontal pockets [Liu et al., 1999],

* mucositis (in children and adolescents undergoing chemotherapy and/or radiotherapy) [Cruz et al., 2007; Cauwels and Martens, 2011],

* eruption disturbances: eruption cyst or haematoma [Boj et al., 2006b], dentigerous or follicular cyst [Boj et al., 2007b], surgical exposure of unerupted or impacted teeth (operculectomy, fenestration) [Asgari et al., 2007; Boj et al., 2008],

* abscess and cyst drainage [Boj et al., 2007b],

* minor salivary gland lesions: mucoceles and ranulas [Boj et al., 2009],

* lesions caused by papilloma virus: squamous cell papilloma [Boj et al., 2007a], focal epithelial hyperplasia [Akyol et al., 2003], oral condyloma acuminatum and verruca vulgaris [Summersgill et al., 2001]; certain papilloma virus serotypes have been linked to squamous cell carcinomas and therefore, the pathological study of these lesions is important [Tinoco et al., 2004],

* other benign mucosal lesions: fibrous hyperplasia, fibromas, diapneusia, epulis (congenital or not), angular cheilitis, benign migratory glossitis, herpes labialis, intraoral herpes, cankers and traumatic ulcers [White et al., 1998],

* gingival melanin pigmentation [Vesnaver and Dovsak, 2006],

* apexogenesis in permanent teeth [Park et al., 2001] and pulpotomy in primary teeth [Odabas et al., 2007]; disinfection after traumatic pulp exposure [Bradley, 1997],

* premalignant lesions (very important previous incisional biopsy): only remove leukoplakia with no dysplasia because lesions with moderate or severe dysplasia require intervention by a specialist physician. The C[O.sub.2] lasers cause the least dispersal of neoplastic cells into the bloodstream [Roodenburg et al., 1991].

Other dental applications of high power lasers that are beyond the scope of this article include tooth whitening [Jones et al., 1999]; dentinal hypersensitivity [Wan-Hong et al., 2004]; hard tissue management (caries removal, placing crowns or dental veneers and ostectomy) [Hadley et al., 2000; Jacobson et al., 2003; Jacobson et al., 2004; Raucci-Neto et al., 2007]; disinfection of root canals and sealing of canaliculi in endodontics [Kimura et al., 2000; Brugnera et al., 2003]; and cleaning before placement of fissure sealants [Brugnera et al., 2006].

All of the above are indications for the use of high power lasers. In addition, low power lasers have bio-stimulating (tissue regeneration), analgesic and anti-inflammatory effects, which are of great use in oral and dental trauma (lacerations, abrasions and concussions), wound healing, paraesthesia, myalgia and temporomandibular disorder [Pinheiro et al., 1998; Brugnera et al., 2006], root canal disinfection and reducing post-operative pain of endodontic surgery [Kreisler et al., 2003]. Lasers also have been used to reduce pain once fixed appliances have been fitted [Lim et al., 1995; Turhani et al., 2006].

Types of lasers used in soft tissue treatment

The word LASER is an acronym of light amplification by stimulated emission of radiation. This is a type of electromagnetic energy that is directional, collimated, monochromatic and coherent (in time and space). These properties distinguish lasers from disordered, incoherent radiation [Nelson et al., 1988]. There are several types of laser. Each one emits light at a specific wavelength that is determined by the gain medium (solid, liquid or gas) [Pick and Powell, 1993]. The effects of a laser on an irradiated tissue depend on the amount of light energy absorbed, which in turn depends on the laser wavelength and the tissue optical properties. Consequently, each laser has a therapeutic application of choice. Not all lasers produce the same effects. In addition, the effect of one type of laser varies according to the tissue and the emission parameters and can even have different effects on the same tissue. In some cases, a specific treatment can be carried out with more than one type of laser. The output (the amount of energy released per unit of time) can be varied by adjusting the laser unit. Handpieces deliver the energy to the target tissues and contain an optical fibre (tip). Thus, the laser energy can be focused or defocused on a larger or smaller area of application, depending on the distance between the tip and the tissue. A higher output is obtained when the laser is applied to a smaller area [Coluzzi, 2000].

Main types of laser therapy. Low level laser therapy (LLLT) or soft lasers use infrared light at a wavelength near visible light. The average output ranges from 50mW to 1W. The laser beam has no thermal effect. Photo-activation produces cell bio-stimulation (analgesic, anti-inflammatory and accelerates healing), particularly in inflamed and oedematous tissue [Gontijo et al., 2005; Brugnera et al., 2006; Turhani et al., 2006]. Therefore, this kind of therapy is very useful post-trauma, in muscle contractures, paraesthesia and TMJ dysfunctions [Pinheiro et al., 1998; Kulekcioglu et al., 2003].

High power, therapeutic or surgical lasers (high level laser therapy) have a clear thermal effect. They focus a large amount of energy on a small space and produce ablation, incision, carbonisation, vapourisation and coagulation of the tissue. Out of the high power lasers described below, the first four are used for soft tissues and the last two for hard and soft tissues.

The Argon laser is the only high power laser that emits visible light: all of the others emit infrared light. Its use in oral surgery is limited to cutting action on soft tissues. Above all, it is indicated for the surgical treatment of vascular or pigmented lesions. Some argon lasers can be used in polymerisation instead of halogen lamps [Hildebrand et al., 2007]. Wilkerson et al. [1996] performed pulpotomies in primary teeth using this laser. Verco [2007] undertook electrosurgical lingual and maxillary fraenectomies using an Argon laser beam. The combined device they used is called the ExplorAr Argon Plasma Cutting Electrodes (APCE) with Argon Beam Coagulator (ABC)[R]. The APCE makes a fast cut and the ABC coagulates blood.

The Diode laser is a solid-state semiconductor laser associated with aluminium, gallium and arsenic. The output is 3.5-15W. Diode lasers have an 800-980nm wavelength in the range of visible and invisible near infrared light. Beams can be emitted in continuous or pulsed (interrupted) mode [Coluzzi, 2000]. Continuous mode is used for soft tissue procedures. This laser has high absorption in tissues pigmented with haemoglobin, melanin and collagen chromophores and low absorption in dental hard tissues. Consequently, it is indicated for surgery of oral soft tissues close to dental structures that does not involve excessive bleeding [Gontijo et al., 2005]. Diode lasers are small and inexpensive. The optical fibre delivery system touches the soft tissue and can be used for ablation, incision and excision (cutting, vapourisation, curretage, coagulation and haemostasis). This type of laser produces a rapid increase in the temperature of the target tissue [Romanos and Nentwig, 1999; Coluzzi, 2000]. Consequently, it is important to control the time of application and the working power to prevent overheating of adjacent tissues, which can lead to necrosis.

Diode lasers should never be used in contact with hard tissue. In periapical and periodontal surgery it is used for disinfection purposes. In endodontics, a fine optical fibre can be used to improve disinfection of root canals along with biomechanical preparation. Romanos and Nentwig [1999] used this laser to perform fraenectomies. In a preliminary study in an animal model, Silvestri et al. [2007] indicated that the diode laser can arrest the formation of the third molar if the mucosal area of the gum is irradiated when the molar is in its bud stage.

Two other neodymium lasers are of interest. The Nd:YAG (wavelength = 1060nm and output = 0.3-6W) and Nd:YAP (wavelength = 1340nm and output = 5W). The behaviour of neodymium lasers is similar to that of diode lasers. They can operate at high or low output [Bradley, 1997] and have limited use in oral surgery. They can be used as an alternative to C[O.sub.2] lasers, as they produce precision cutting, haemostasis and simultaneous disinfection [Braggett et al., 1999]. However, their cutting efficiency is slightly slower than C[O.sub.2] lasers. They are useful in the treatment of vascular lesions and gingival melanin pigmentation [Matsumoto and Hossain, 2002; Vesnaver and Dovsak, 2006]. In addition, they act as a disinfectant in endodontics and periodontics, as they are an effective bactericide [Brugnera et al., 2003]. An Nd:YAG laser in combination with a diode laser is available on the market. Fornaini et al. [2007] used this laser to perform treatments on orthodontic patients, including fraenectomies, fenestrations of unerupted teeth and gingivectomies, with excellent results.

Carbon dioxide lasers (gas medium; recommended output = 3-10W; wavelength: 10,600nm) have a very high water absorption coefficient, regardless of the colour of the tissue. This laser is well absorbed by all soft tissues that have high water content. The effect on adjacent, non-targeted tissues is minimal. No direct contact with the target tissue is required. The beam can be focused (cutting effect) or defocused (vapourisation). These lasers generate a lot of heat and burn tissue fast. The charred layer should not be removed, as it acts as a biological cover [Tamarit et al., 2005]. In oral surgery, C[O.sub.2] lasers produce excellent intra-operative coagulation of small blood vessels and immediate sterilisation of the surgical field and reduce the inflammatory reaction and scar formation. Consequently, they are widely used in the surgical management of oral soft tissues. An incisional biopsy should be carried out prior to treatment with this laser [Huang et al., 2007]. Carbon dioxide lasers are very safe and effective for soft tissue surgery in developing countries [Kato and Wijeyeweera, 2007]. With this laser, the risk of disseminating cancer cells or producing bacteraemia is virtually nil [Tamarit et al., 2005].

The Er,Cr:YSGG: (erbium, chromium, yttrium, scandium, gallium and garnet laser) type of laser has a 2,780nm wavelength. It cuts calcified tissues (enamel, dentine, cement and bone) safely and effectively, due to a hydrokinetic system of photon liberation in an air-water spray, and can be used instead of a rotary instrument. Ablation of enamel and dentine occurs when the organic components absorb the irradiated energy, which produces vapourisation of the water and of the hydroxyl ions in the apatite mineral. At low output, it desensitises dentine [Jacobson et al., 2003; Raucci-Neto et al., 2007]. Due to its versatility, this type of laser is one of the most commonly used in paediatric dentistry. It can be used on soft and hard tissue and is associated with a reduction in discomfort, oedema, scarring and wound shrinkage. The air-water spray allows histological studies to be carried out on removed lesions, as the tissue is not overheated during the procedure [Boj et al., 2005a, 2005b].

The Er:YAG (Solid state medium of garnet, aluminiumscandium and yttrium stimulated with erbium) is an invisible infrared laser of 2,940nm and is a pulsed laser that uses an optical fibre delivery system. It is effective on hard and soft tissues, similarly to the slightly older Er,Cr:YSGG laser. It is useful for soft tissue surgery that is not extensive [Gontijo et al., 2005]. The fibre-optic delivery system can be used to disinfect root canals along with the conventional biomechanical preparation, with results similar to those of 1% hypochlorite solution [Brugnera et al., 2003].

Argon, diode, neodymium, Er:YAG, Er,Cr:YSGG and C[O.sub.2] lasers have been approved by the USA Food and Drug Administration (FDA) for oral surgery [Keller et al., 1998]. The use of these lasers in various surgical processes has been well documented [Pick and Colvard, 1993; Coluzzi 2000; Martens, 2003; Stabholz et al, 2003; Strauss and Fallon, 2004].

Laser safety

There are several contraindications for laser therapy, of which operators should be aware [Basford, 1995]. In addition, the following safety measures should be taken into account. The eyeball should not be directly or indirectly (through reflection) irradiated when visible or infrared radiation is used at wavelengths of 400-1400nm, due to the risk of retinal damage. Consequently, the dentist, patient and anyone in the vicinity of the treatment area must use safety goggles as indicated by the manufacturer. This measure applies to the use of any type of laser, including soft lasers.

The skin of staff and patients should be protected to ensure that no tissues outside the surgical field are burned. The interaction of the laser with a tissue has a photo-thermal effect. Depending on the absorption, the temperature can produce transient hyperthermia (42-45[degrees]C), coagulation (70-90[degrees]C) or carbonisation (>200[degrees]C). Lasers with the highest absorption in soft tissues (C[O.sub.2] laser) rapidly produce temperatures of 1,700[degrees]C at the point of application. However, less heating occurs in adjacent tissues than with other lasers that have lower absorption coefficients (diode and Nd:YAG lasers). Overheating of adjacent tissues may lead to necrosis. The accumulated thermal effect depends on the time of application (continuous emission or pulsed). Erbium lasers produce less thermal damage, as they are pulsed and use air-water as a cooling system. In addition, they are highly absorbed by intrinsic water [Strauss and Fallon, 2004].

Advantages of the laser over conventional surgery

Analgesia. The use of lasers reduces the amount of local analgesia required and can reduce the perception of pain in some cases [Boj et al., 2005a]. Authors such as Jacobson et al. [2003, 2004] and Boj et al. [2006a, 2006b] using an Er,Cr:YSGG laser and Fornaini et al. [2007] with Nd:YAG and diode lasers performed dental treatments on children without local infiltration analgesia. Other authors did use analgesia [Kopp and St Hilaire, 2004], although doses were lower than normal in some cases [Kato and Wijeyeweera, 2007; Boj et al., 2009].

Haemostatic properties. These properties are significant, due to the high vascularity of the oral cavity [Martens, 2003]. They are extremely useful in vascular lesions and in areas with a rich blood supply, such as the sublingual region, in the case of frenectomies [Matsumoto and Hossain, 2002]. The carbon dioxide laser provides the best intra-operative control of bleeding, which enables precise surgery to be performed, as it is easier to identify anatomical structures when there is no bleeding in the surgical field [Kopp and St Hilaire, 2004; Kato and Wijeyeweera, 2007]. The Er,Cr:YSGG laser also has anticoagulant properties when the percentage of air-water is reduced, which produces a greater thermal effect [Wang et al., 2005]. The argon laser has also been used as a coagulator in areas with a high density of blood vessels, such as the lingual fraenum [Verco, 2007]. Erbium lasers have less of a haemostatic effect than C[O.sub.2] and Nd:YAG lasers [Strauss, 2000; Strauss, 2004].

Sutures. The need for sutures is eliminated, as haemostasis enables wounds to heal by secondary intention. Exceptionally, some authors have used sutures after C[O.sub.2] laser use [Kopp and St Hilaire, 2004].

Lasers are cicatrizants. They improve wound healing, which occurs faster and with less scarring than after conventional treatments. Lasers are good treatment options for ulcers and mucositis [Wong and Wilder-Smith, 2002]. Healing is fastest after the application of erbium lasers, as they have a low thermal effect [Wang et al., 2005]. In addition, the defocused use of a C[O.sub.2] laser at the base of a lesion completes haemostasis and enables immediate contraction of the surgical site, with a 30-40% reduction in wound size. As no mucosal tissue is lost, unaesthetic scar formation caused by wound tension is avoided [Kopp and St Hilaire, 2004; Kato and Wijeyeweera, 2007].

Antibacterial/disinfectant properties. These properties enhance post-operative recovery and reduce the required dose of antibiotics [Turkun et al., 2006]. According to Kato et al. [2007], lasers are very useful in developing countries where patients have high post-operative morbidity and mortality, as infections are prevented.

Anti-inflammatory properties. Treatments that are undertaken with C[O.sub.2] and Er,Cr:YSGG lasers cause less oedema and post-operative pain, which reduces the required doses of analgesics and anti-inflammatory drugs. As the C[O.sub.2] laser cuts soft tissue, it seals nerve endings, blood and lymph vessels, which reduces the inflammatory reaction [Tamarit et al., 2005]. The anti-inflammatory properties of low level lasers can be used to treat muscle contractures and traumas [Turkun et al., 2006].

Operating time. Lasers reduce the operating time needed for soft tissue management. For example, with the C[O.sub.2] laser, the removal of a mucocoele takes 3-5 minutes; a gingivectomy 2 minutes; a maxillary fraenectomy 1.5 minutes; and a lingual fraenectomy 2 minutes [Huang et al., 2007; Kato and Wijeyeweera, 2007].

Vibration. The patient does not feel any vibration, pressure, or the contact of the optical fibre on the tooth, as occurs with a rotary instrument. This increases a patient's collaboration [Keller et al., 1998; Jacobson et al., 2003] and acceptance of the procedure [Genovese and Olivi, 2008].

Post-operative care. Lasers improve post-operative comfort, due to haemostasis, the lack of sutures, and the pain reduction. This is very useful in young patients [Fornaini et al., 2007]. In papers on fraenectomies performed with lasers and with conventional techniques, it was observed that there was less post-operative pain and discomfort, less functional complications and more patient satisfaction after the laser therapy [Haytac and Ozcelik, 2006; Kara, 2008].

Discussion

As stated in the introduction, laser technology can be used in children for the healing of most oral soft tissue lesions [Brugnera et al., 2006; Martens, 2011; Olivi and Genovese, 2011] instead of conventional methods (cold knife, electrocautery or cryosurgery) [Ishida and Ramos-Silva, 1998].

The lasers of choice for soft tissue management are the Nd:YAG, C[O.sub.2] and diode lasers [Parkins, 2000]. There is extensive literature on soft tissue management with C[O.sub.2] lasers in children, as this procedure is considered safe and has many intra-operative and post-operative advantages [Tamarit et al, 2005; Kato and Wijeyeweera, 2007]. Some authors have used the Nd:YAG laser in children [Braggett et al, 1999], whilst others consider that the combination of Nd:YAG and diodes is more effective [Fornaini et al., 2007].

In recent years, the number of papers on the use of Er,Cr:YSGG lasers in paediatric dentistry has increased as this type of laser is very versatile, commonly used for hard tissue applications but can readily be used for soft tissues [Hadley et al., 2000; Boj et al., 2005b, 2006a, 2008, 2009]. The handpiece is similar to that of a conventional turbine, which facilitates clinical management. The technique is easy, reducing the duration of intervention. Its haemostatic effect enhances visibility of the surgical area, which is a major advantage in children's small mouths. Scarring is minimal (no tissue retraction) and eliminates the need to suture. Lasers reduce post-operative oedema, bleeding, infection and pain, and thus the use of medications [Boj et al., 2007].

For labial fraenectomies, Gontijo et al. [2005] used a combination of a diode laser to manipulate soft tissues and the Er:YAG laser for the periosteum and the final collagen fibres. Erbium lasers allow for fast healing, due to their minimal thermal effect, however surgery is not completely bloodless, as it is with the C[O.sub.2] laser. Therefore, compression is sometimes required to achieve haemostasis. Diode or Nd:YAG lasers are preferable for the management of highly vascular lesions, as they have a major coagulating effect [Tamarit et al., 2005].

The main laser safety measures are as follows. Eye and skin protection is required for the dentist, patient and any staff in the vicinity of the work area, to avoid retinal damage or burns. As a small proportion of the laser energy is not used in the ablation process and causes heat in dental structures, it is important to ensure that the pulp is not damaged with certain lasers (C[O.sub.2] and Nd:YAG), that should only be used for soft tissue ablation [Jacobson et al., 2003; Matsumoto and Hossain, 2002], as a temperature rise of over 5[degrees]C causes irreversible pulp damage. Consequently, erbium lasers, with the correct proportion of air-water, are now used in hard tissue treatments without tissue overheating [Rizoiu et al., 1998; Raucci-Neto et al., 2007].

Certain types of laser (C[O.sub.2] and Nd:YAG) cause vapourisation of the tissue, and if histopathological analysis is required, a biopsy must be performed with a cold knife before laser surgery [Tamarit et al., 2005]. Tran et al. [1999] and Boj et al. [2007a, 2009] indicated that tissues removed with an Er,Cr:YSGG laser can be analysed histopathologically, if they do not receive the impact of the laser on removal, a low power (1.5W) is used and an air-water spray (10% water and 11% air) prevents overheating of the surrounding tissue.

In the past, soft tissue surgical procedures were often rejected in children, as problems with cooperation meant that they could not be performed without general anaesthesia [Kotlow, 2004]. Several authors have stated that the use of lasers causes less discomfort and is well-accepted by young patients and their parents. Thus, lasers can reduce psychological trauma and fear during the dental visit [Matsumoto and Hossain, 2002; Gontijo et al., 2005].

The use of lasers in paediatric dentistry is still not widespread despite their great versatility (some lasers are more versatile than others). This could be due to the high cost of laser units, the lack of education about lasers in undergraduate courses and the fact that training is required. Nevertheless, in some dental treatments, the laser is an irreplaceable tool, rather than the marketing device that some dentists consider it to be. An increasing amount of literature on clinical indications and protocols indicates that the laser is a tool with great future potential in this field [Boj, 2005b].

Conclusion

Although the most commonly used laser for soft tissue management has been the C[O.sub.2] laser, the Er,Cr:YSGG laser represents a therapeutic alternative in most paediatric oral surgery, and produces excellent results. Professionals must know the physical characteristics of the laser and its interactions with biological tissues to be able to use the device safely. It is also essential to know the indications of each type of laser.

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J.R. Boj *, C. Poirier *, M. Hernandez *, E. Espasa *, A. Espanya **

Depts of * Paediatric Dentistry, ** Oral Surgery, Dental School, University of Barcelona, Barcelona, Spain.

Postal address: Prox Juax Boj. Dept. of Paediatric Dentistry, Dental School, University of Barcelona, Campus de Bellvitge, c. Feixa Llarga s/n, 08907 Hospitalet de Llobregat, B[degrees]rcelona, Spain.

Email: 16388jrb@comb.cat
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