Is COIs CO2 2 laser superior to laser superior to Is COIs CO2 2 laser superior to laser superior to conventional surgery in conventional surgery in

P t ti ll M li t l l i ?P t ti ll M li t l l i ?Potentially Malignant oral lesions?Potentially Malignant oral lesions?

H E S H A M A F A T T A H O R L & H & N S U R G

H A N A N I B R F A H I M O R A L M F S U R GH A N A N I B R F A H I M O R A L M F S U R G

H A L A A B D A L - A L E E M O R A L M F S U R G

T A I S S I R O M A R O R A L P A T H N O U R A NA B O U K H A D E R D E R M A & V E N E RA B O U K H A D E R D E R M A & V E N E R

InIn 19831983 WW HH OO firstfirst defineddefined oraloral leukoplakialeukoplakia asas aa whitewhite patchpatchoror plaqueplaque thatthat couldcould notnot bebe characterizedcharacterized clinicallyclinically orororor plaqueplaque thatthat couldcould notnot bebe characterizedcharacterized clinicallyclinically ororpathologicallypathologically asas anyany diseasedisease

Erosive Erosive HypertrophicHypertrophic

study group

lichen planuslichen planus

BullousBullous

AtrophicAtrophic

ltrt

ltReticularReticularReticularReticular

lichen lichen planus planus on on cheek mucosacheek mucosa

AIM OF THE WORK O O

tt l tl t thth C bC b Di idDi idtoto evaluateevaluate thethe useuse CarbonCarbon DioxideDioxideLaserLaser inin surgicalsurgical removalremoval ofofPotentiallyPotentially MalignantMalignant OralOral LesionsLesions..

Material & MethodsMaterial & Methods

study 40 patients with Potentially Malignant Lesions study 40 patients with Potentially Malignant Lesionslesions were selected from the outpatient clinic of theOral and Maxillofacial Surgery Department, FacultyOral and Maxillofacial Surgery Department, Facultyof Dentistry and from the outpatient clinic of theOtolaryngology Head & Neck Surgery andDermatology Department, Faculty of Medicine,Alexandria University.

h i h hl d b h ll The patients were thoroughly screened both orallyand medically and were chosen such as to be freefrom any dental or medical complicating factors orfrom any dental or medical complicating factors ordisease.

Material & MethodsMaterial & Methods

Th l t d d l ll t d i t Th l t d d l ll t d i t 2 2 q l q l The selected cases were randomly allocated into The selected cases were randomly allocated into 2 2 equal equal groups:groups: 11--Control Group:Control Group: Conventional surgical Excision using scalpelConventional surgical Excision using scalpel11 Control Group:Control Group: Conventional surgical Excision using scalpelConventional surgical Excision using scalpel

22--Study Group: Study Group: COCO22 laser laser EvapourationEvapouration and / and / orExcisionorExcision

Patients Selection Patients Selection . . The inclusion criteria were:The inclusion criteria were:

Oral Potentially Malignant lesions.Oral Potentially Malignant lesions.

Th bi i d th l b i ith d l ti h b Th bi i d th l b i ith d l ti h b hi t thhi t th The biopsied pathology was benign or with dysplastic change by The biopsied pathology was benign or with dysplastic change by histopathhistopathexamexam

The exclusion criteria :The exclusion criteria :

Unbiopsied lesion: any patient presenting without pathological report Unbiopsied lesion: any patient presenting without pathological report

Patients suffering from systemic diseases that would jeopardize the Patients suffering from systemic diseases that would jeopardize the surgery such as diabetes, hypertension, cardiac disease, hormonal surgery such as diabetes, hypertension, cardiac disease, hormonal disturbance, renal disease and hematological disorder.disturbance, renal disease and hematological disorder.

MethodsMethods

PatientPatient consentconsent PatientPatient consentconsentAA legallegal consentconsent formform carryingcarrying detaileddetailed informationinformation aboutabout thethe naturenature ofof thethe surgerysurgery withwith itsits risk,risk,

advantagesadvantages andand disadvantagesdisadvantages asas wellwell asas anyany potentialpotential occurrenceoccurrence ofof complicationcomplication waswas signedsignedbyby thethe patientspatients..

II P i lP i l hh II-- PresurgicalPresurgical phasephase11-- HistoryHistory ofof patientpatientAA comprehensivecomprehensive historyhistory waswas takentaken includingincluding personalpersonal datadata:: name,name, age,age, gender,gender, occupation,occupation,

address,address, maritalmarital status,status, relievingrelieving andand aggravatingaggravating factors,factors, presencepresence oror absenceabsence ofof associatedassociatedii dd ff hh D il dD il d bb dd di ldi l dd d ld l hi ihi i ddpainpain andand raterate ofof growthgrowth.. DetailedDetailed aboutabout pastpast andand presentpresent medicalmedical andand dentaldental historieshistories andand

previousprevious biopsybiopsy reportsreports..22-- ClinicalClinical examinationexaminationAA throughthrough clinicalclinical examinationexamination includingincluding extraextra oraloral andand intraintra oraloral inspectioninspection andand palpationpalpation toto

tt ll b litb lit dd l hl h dd t tt tassessassess anyany extraextra oraloral abnormalityabnormality andand lymphlymph nodenode statusstatus..IntraIntra oraloral examinationexamination ofof thethe lesionlesion includingincluding sitesite ,, size,size, surface,surface, color,color, shape,shape, texturetexture andand

consistencyconsistency..3- Pre operative preparation

All ti t h it li d d h d l d f ti All patients were hospitalized and scheduled for operation. Antiseptic oral rinses were in the patients' schedule. Prophylactic Amoxicillin 500mg capsules every 8 hours.

IIII-- Surgical techniqueSurgical techniqueSu g ca tec queSu g ca tec que

BB--LaserLaser surgerysurgery (Study(Study group)group)BB LaserLaser surgerysurgery (Study(Study group)group) aa--VaporizationVaporization positionposition:: TheThe CarbonCarbon dioxidedioxide laserlaser waswas adjustedadjusted atat 1010 wattswatts andand

thethe handhand piecepiece 250250mmmm focalfocal distancedistance waswas heldheld atat distancedistance ofof 1010--1515mmmm fromfromtargetedtargeted tissuetissue withwith continuouscontinuous supersuper pulsepulse withwith defocuseddefocused modemode..

VaporizationVaporization waswas performedperformed onon largerlarger surfacesurface lesionslesions andand inin anatomicanatomic areasareas wherewhere VaporizationVaporization waswas performedperformed onon largerlarger surfacesurface lesionslesions andand inin anatomicanatomic areasareas wherewhereexcisionexcision couldcould compromisecompromise adjacentadjacent anatomicanatomic structures,structures, suchsuch asas thethe floorfloor ofof thethemouthmouth .. SinceSince vaporizationvaporization depthdepth isis limitedlimited passpass inin continuouscontinuous mode,mode, underlyingunderlyinganatomicanatomic structuresstructures couldcould bebe preservedpreserved withwith lessless scarringscarring andand greatergreater preservationpreservationofof thethe elasticelastic propertiesproperties ofof tissuetissueofof thethe elasticelastic propertiesproperties ofof tissuetissue..

bb--CuttingCutting positionposition:: TheThe COCO22 laserlaser isis operatedoperated inin focusedfocused modemode.. WhenWhen cuttingcutting waswas requiredrequired;; thethe laserlaser beambeam waswas changedchanged fromfrom thethe vaporizationvaporization

positionposition toto thethe cuttingcutting positionposition byby changingchanging thethe distancedistance toto 55--1010 mmmm fromfrom targetedtargetediitissuetissue..

FocusedFocused modemode occursoccurs whenwhen thethe spotspot sizesize isis maintainedmaintained atat thethe focalfocal pointpoint ofof thethe laser,laser,resultingresulting inin thethe smallestsmallest possiblepossible spotspot sizesize ofof thatthat particularparticular laserlaser..

InIn focusedfocused mode,mode, thethe powerpower perper unitunit areaarea isis maximizedmaximized andand thethe depthdepth ofof cutcut isisInIn focusedfocused mode,mode, thethe powerpower perper unitunit areaarea isis maximizedmaximized andand thethe depthdepth ofof cutcut isisincreased,increased, resultingresulting inin aa deep,deep, thinthin cutcut asas wouldwould bebe seenseen withwith aa scalpelscalpel givengiven aa zonezoneofof laterallateral necrosisnecrosis.. TheThe incisionincision waswas performedperformed inin oneone oror twotwo pathspaths byby connectingconnectingthethe outlinedoutlined dotsdots atat aa controlledcontrolled yetyet rapidrapid raterate ofof motionmotion

IIIIII-- Post surgical phasePost surgical phaseost su g ca p aseost su g ca p ase

Post operative instructions were given to the patients which included applying Post operative instructions were given to the patients, which included, applyingice packs extra-orally on the first day to minimize edema, warm mouthwashstarting the day after surgery for 5 days.

1 Post operative medication1- Post operative medication

Oral hygiene instructions, including using soft tooth brush and rinsing withwarm Hexitol mouth wash* (Chlorohexidine HCl 0.2%), twice daily.

Post operative Amoxicillin* 500mg capsule every 8 hours for 5-7 days

Non-steroidal anti inflammatory analgesic in the form of Diclofenacpotassium** 50 mg tablets to avoid possibility of inflammation, edema, andpain.

2-Clinical evaluation

The patients were given appointments for clinical follow up after one daye pat e ts e e g e appo t e ts o c ca o o up a te o e daypostoperative, one week, 12 weeks and 24 weeks to asses pain, infection, localedema, effect to adjacent structure, healing and recurrence

Parameters EvaluatedParameters Evaluated

1- Presence of pain

Using visual analogue scale "five-face scale" for painintensity

2-Infection

Patients are examined for any signs of infection assuppuration or wound dehiscence.

3- Post operative edema

By using tape-measuring method

h h f h dThe arithmetic of the two measurements determinethe facial measure. The percentage of facial swellingwas obtained from the difference betweenmeasurements made in the preoperative andpostoperative periods, dividing the result by thep p p , g yvalue obtained in the preoperative period, andmultiplying it by 100.

4- Effect to adjacent structures

Effects on nerves, mobility of tongue and lips

5-Healing

Determine the normal oral mucosa and soft tissue.

6- Recurrence

was observed with respect to original lesion.WalshWalsh LJLJ ClinicalClinical evaluationevaluation ofof dentaldental hardhard tissuetissueWalshWalsh LJLJ.. ClinicalClinical evaluationevaluation ofof dentaldental hardhard tissuetissueapplicationsapplications ofof carboncarbon dioxidedioxide laserslasers..JJ ClinClin LaserLaser MedMed SurgSurg 20042004;; 1212:: 1111--55..

ResultsResults

G 1G 1 G 2G 2

FactorsFactors

Group 1Group 1

(Control)(Control)

N= N= 2020

Group 2Group 2

(Study)(Study)

N= N= 2020

TestTest

P valueP valueN= N= 2020 N= N= 2020

Sex Sex Male Male 6 (306 (30%)%) 8 8 (40%)(40%)1.001.00

Female Female 14 (7014 (70%)%) 1212 (60(60%)%)A A MiMi 66 88Age Age MinMin-- maxmax 2929-- 6262 2424-- 7878 0.240.24

0.810.81Mean Mean ±± SDsSDs 43.8 43.8 ±± 10.710.7 45.3 45.3 ±± 16.416.4Diagnosis Diagnosis Lichen planus Lichen planus 16 16 (80%)(80%) 16(8016(80%)%) 2 002 00ag os s ag os s c e p a us c e p a us 6 6 (80%)(80%) 6(806(80%)%) 2.002.00

0.570.57ErythroplakiaErythroplakia 2 2 (10%)(10%) 2 2 (10%)(10%)LeukoplakiaLeukoplakia 2(102(10%)%) 2(102(10%)%)

Side Side Unilateral Unilateral Right Right 10 10 (50%)(50%) 2 2 (10%)(10%) 66Side Side Unilateral Unilateral Right Right 10 10 (50%)(50%) 2 2 (10%)(10%) 4.674.67

0.100.10Left Left 6 6 (30%)(30%) 6 6 (30%)(30%)

Bilateral Bilateral 4 4 (20%)(20%) 12 12 (60%)(60%)

Group 1 Group 2 Factors

Group 1 (Control)

Group 2 (Study)

iMin- max1-20 1-25

Mean ±SD 6.6 ± 4.2 10.8 ± 8.1SDT test 1.48P value 0.15

Comparison of size (cm) between lesions Comparison of size (cm) between lesions Comparison of size (cm) between lesions Comparison of size (cm) between lesions of control and study groups.of control and study groups.

Histopathological appearances of a case of lichen planusHistopathological appearances of a case of lichen planus

aa-- PreoperativePreoperative:: LichenLichen planusplanus showingshowing

hyperkeratosishyperkeratosis andand subepithelialsubepithelial

lymphocyticlymphocytic bandicbandic changeschanges (X(X100100))

bb-- PostoperativePostoperative:: LichenLichen planusplanus withwith mildmild

dysplasticdysplastic changeschanges andand showingshowing sawsaw--

toothedtoothed reterete ridgesridges (X(X100100))lymphocyticlymphocytic bandicbandic changeschanges (X(X100100)).. toothedtoothed reterete ridgesridges (X(X100100))..

th l ki ith d t ith li l d l i (Xth l ki ith d t ith li l d l i (X100100))leukoplakia with mild dysplasia (X100).leukoplakia with mild dysplasia (X100). erythroplakia with moderate epithelial dysplasia (Xerythroplakia with moderate epithelial dysplasia (X100100).).

A partial missing of epithelium with

liquefaction degeneration of the basal

B- moderate epithelial dysplasia and

liquefaction degeneration of the basal

moderate epithelial dysplasia showing partial necrosis of

ith li d tiliquefaction degeneration of the basal

cells and prominent subepithelial

lymphocytic band (X100).

liquefaction degeneration of the basal

cells(X200).epithelium and connective tissue(X100)

Preop Biopsy Postop Biopsy

Erosive Lichen Planus

a-Preoperative: Showing bullous lichen planuswith mild epithelial dysplasia (separationbetween epithelium and connective tissue wasnoted) (X200).

b-Postoperative: Showing total necrosis ofsurface epithelium and connective tissue(X200)

a- Preoperative: Hypertrophic lichen planus

showing hyperkeratinization of acanthotic

ifi d i h li i h

b- Preoperative: Higher magnification

reveals liquifactive degeneration of basal

ll l d b h h i i

c- Postoperative: Total necrosis of both epithelium and connective tissue(X100).

stratified squamous epithelium with

lymphocytic band (X100).

cells replaced by the characteristic

civatte bodies (X200).

a- Preoperative: Showing b- Postoperative: Showing a- Erythroplakia showing severe b- mild necrosis of theleukoplakia with

moderate epithelial

dysplasia (X100).

partial necrosis of

epithelium and connective

tissue (X200).

epithelial dysplasia (X200). epithelium and the connective

tissue of MWD SCC with

persistent individual cell

kertinization (X100).

Histopathological Findingsp g g

DysplasiaStudy Number %DysplasiaControl Number %Clinical Diagnosis DysplasiaStudy-Number %DysplasiaControl-Number %Clinical Diagnosis

4 ( moderate)6 (30%)08 (40%)Erosive lichen planus

2 (mild)4 (20%)2(mild)4 (20%)Atrophic lichen planus

04 (20%)02 (10%)Hypertrophic lichen planus

2 (mild)2 (10%)02 (10%)Bullous lichen planus

L k l ki2(moderate)2 (10%)2(mild)2 (10%)

Leukoplakia

2 (severe)2 (10%)2 (moderate)2 (10%)Erythroplakia

1220620Total 1220620Total

Af hAf hAfter one weekAfter one week After 3 monthsAfter 3 months

6 6 monthsmonths

One wkOne wk

3 3 monthsmonths 6 6 monthsmonths

33monthsmonths

6months6months

33monthsmonths33monthsmonths

6months

Moderate dysplasiaModerate dysplasia

O kO k

Moderate dysplasiaModerate dysplasia

One wkOne wk

6 6 monthsmonths

3 3 monthsmonths

FactorsGroup 1 (Control)

N= 20

Group 2 (Study)

N= 20Min- max 20- 35 10-25Mean ± SD 24.00 ± 5.16 16.00 ± 5.16

Factors Control N= 20 Study N= 20

Min- max 20- 50 10-25

Mean ± SD 35.00 ± 10.80 17.00 ± 5.38T test/ P value 3.46 0.003* T test /P value 4.72 <0.0001*

MWU test 1.36P value 0.17 T 5.54

P <0.0001*

Postoperative Pain after Postoperative Pain after 1 1 wkwk Postoperative Edema after Postoperative Edema after 1 1 daydayPostoperative Pain after Postoperative Pain after 1 1 wkwk Postoperative Edema after Postoperative Edema after 1 1 dayday

RecurrenceRecurrence

Control group ( Control group ( 2 2 cases)cases)•erosive lichen planus •reticular lichen planus •reticular lichen planus

study group (study group (2 2 cases )cases )•atrophic lichen planus with mild epithelial dysplasia •bullous lichen planus with mild epithelial dysplasia •bullous lichen planus with mild epithelial dysplasia

CO2 in the oral cavity is superiorto conventional surgery as regardto conventional surgery as regardintraoperative time & amount ofbleeding as well as postoperativeedema

Healing after CO2 laser is fasterl if fi i l i ionly if superficial evaporation is

utilized

It d i l q i tIt needs special equipment,preparation, and training