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Case Report: Surgical Management of Oral Leukoplakia: A Case of Laser Excision

 Surgical Management of Oral Leukoplakia: A Case of Laser Excision
Dr. Soni Bista,1
 Dr. Rebicca Ranjit,2
 Dr. Suraksha Subedi3
1,3Department of Periodontology and Oral Implantology, Gandaki Medical College, Kaski, Nepal
Correspondence : Dr. Soni Bista. Email: sonibista1234@gmail.com

ABSTRACT
Oral leukoplakia is the most frequent potentially malignant disorder of the oral mucosa which requires
definite treatment. A wide variety of medical and surgical treatment modalities have been endeavoured
with varying degrees of success. Among various surgical treatments, laser techniques have helped
improve surgical approaches and ultimate control of leukoplakia. The present case reports homogenous
leukoplakia in an adult male treated successfully with diode laser and followed up for six months without any complications and recurrence. Thus, the application of diode laser is safe and can be effectively used as a good substitute for the management of oral leukoplakia.

Keywords: Diode lasers; laser therapy; oral mucosa; oral leukoplakia.

INTRODUCTION
The term leukoplakia is recognized as white patches of questionable risk having excluded known diseases or disorders that carry no increased risk for cancer.1 The cause is multifactorial including tobacco or areca nut use, alcohol abuse, human papilloma virus, fungal infections, chronic
trauma, and nutritional deficiency.2
 
Different modalities for its management includes medical therapy (antioxidants, Vitamin A), surgical therapy using scalpel, electrocautery, and laser.3 Surgical excision done by soft tissue diode laser have shown beneficial role in the treatment of the lesion.4 This paper reports a case of oral leukoplakia treated successfully with the application of diode laser.

CASE REPORT
An adult male aged 60 years reported to the Department of Periodontology and Oral Implantology of Universal College of Medical Sciences, Bhairahawa, Rupandehi, Nepal with a chief complaint of white patches on his right lower back gum region for two years. The patient’s medical history and family history were non-contributory. He had the habit of smoking tobacco, one pack of bidi (25 bidis) per day for 10 years. On extraoral examination, there were no significant findings.
On intraoral examination, white plaques were appreciated on right lower buccal gingiva of the posterior teeth extending from the first premolar to the second molar involving their marginal, attached and papillary gingiva (Figure 1). The lesion was non-scrappable, had firm consistency, diffused margins, wrinkled surface, crack-mud appearance measuring approximately 7x4 cm2 with normal surrounding mucosa. Class II Gingival recession was observed in relation to #46 (according to two-digit numbering system). Furthermore, stain and calculus were present in all teeth. The provisional diagnosis was made as homologous leukoplakia on right buccal gingiva in relation to #45, #46, and #47 because at clinical examination a predominantly white lesion was appreciated which cannot be clearly diagnosed as any other disease or disorder of the oral mucosa. 
Following an initial examination and treatment planning discussion, the patient underwent nonsurgical periodontal therapy including scaling and root planing with oral hygiene instructions. He was given strict advice for complete cessation of the habit of smoking tobacco and prescribed with Tablet BNM forte (Lycopene, Meobalamin, Omega three with multivitamin) twice daily for a month. Meanwhile, a punch biopsy with a diameter of 0.5 cm (involved and normal tissue) of the lesion from marginal and attached gingiva in relation to #45 was sent for histopathological examination as it is mandatory to rule out any malignancy (Figure 2). The histopathological analysis revealed a hyperkeratinised stratified squamous epithelium with mild dysplasia (Figure 3). On the basis of clinical presentation and histopathological reports, a definite diagnosis of Homogenous Leukoplakia with mild dysplasia on buccal gingiva in relation to #45, #46, and #47 was made. The patient did not respond to conservative medical management with multivitamins, multiminerals, and antioxidants (Tablet BNM forte) even after a month of followups, so he was advised for complete excision of the lesion using a diode laser. A complete haemogram was done which depicted values within normal limits. Written informed consent was taken from patient. 



On the day of surgery, a complete protocol for surgical preparation was followed. The patient was asked to do a presurgical mouthrinse using 2 ml of 0.2% chlorhexidine diluted solution, and 5% povidone-iodine solution (Betadine) was used to perform extraoral antisepsis. Right inferior alveolar nerve block using 2% lignocaine with adrenaline 1:200,000 was administered. Safety measures were taken for the operator, patient, and assistants by wearing the recommended laser protective eyewear. High-speed suction and surgical masks were used to prevent infection from the laser plume. Diode laser (iLase™) emitting 940 nm was used for excision where a preset value was adjusted: power of 3.00 W, pulsed contact mode, continuous pulse duration, and pulse interval of 1.00 ms. Blunt end of the probe was used to check for objective symptoms. After the area was anaesthetised, the excision of the lesion in the right lower posterior gingiva and buccal mucosa was carried out using a bendable laser tip with a diameter of 300 mm (Figure 4). After excision, the surgical site was wiped off with a cotton pellets soaked in normal saline. The operated site was then protected with periodontal dressing (COE–PAKTM GC America) (Figure 5, 6). The entire procedure was painless with no bleeding and lesser intraoperative time.

Post-surgical instructions were given with the prescription of analgesics (Ibuprofen 200 mg, if needed) and warm saline rinse (three to four times/day for two weeks). To minimise traumatic injury to the wound, mechanical tooth cleaning was restricted to the surgical site for the first week. The patient was recalled immediately after a week for removal of periodontal dressing then after two weeks and six months for revaluation (Figure 7, 8). No complication without recurrence was observed at follow-ups.

DISCUSSION 
The management protocol for leukoplakia should be based on grade of dysplasia, size, and location of the lesion; however, local factors such as trauma and adverse habits such as using tobacco should be controlled. Both non-surgical and surgical treatment modalities can be applied with varying success. In non-surgical methods, anti-inflammatory agents, carotenoids, retinoids, antimycotic agents, and cytotoxic agents can be used topically. Chemopreventive agents such as vitamins (A, C, E), fenretinide (Vitamin A analogue), carotenoids (beta carotene, lycopene), green tea, curcumin are also beneficial. They play a vital role during the early healing of the lesion but they will appear once the patient stops taking the supplements. Researchers have found it to be less convincing and possessing a longer duration of treatment. In the present case, combination of multivitamins, multiminerals, and antioxidants drug was prescribed to the patient for a month, but it did not show any effect. Thus, surgical excision was opted as an appropriate treatment for the case. Surgical treatment can be carried out using scalpel, cryotherapy, electrocautery, and laser, but will not prevent all premalignant lesions from undergoing malignant transformation, which can be explained by the genetic defects even in the normal appearing mucosa surrounding the excised lesion (field cancerisation).4 Surgical excision of lesions using laser offers several advantages over scalpel excision which includes bloodless surgical and postsurgical events; the ability to precisely coagulate, vaporise, or cut tissue; minimal swelling and scarring; reduction of surgical time, postsurgical pain with high patient acceptance.5 Previous study has evidenced promising results using lasers in the excision of oral leukoplakia.6 The diode laser is not indicated as the main laser for soft tissue surgery, but its versatility of use led us to choose it for the study. In the present case, the patient reported minimal intraoperative and post-operative pain and discomfort. These results are similar to the findings of Mohan et al., who reported minimal post-operative pain and discomfort.7 The wound healing was also satisfactory similar to the previous study.7 Histologically, laser-created wounds heal more quickly and produce less scar tissue than conventional scalpel surgery,8 although contrary evidence also exists.9 In the present case, the patient did not show any signs of recurrence in six months’ follow-up. This was similar to the findings of a study conducted in Natekar et al.,10 the patients in their study showed no sign of recurrence on six months’ follow-up. Although laser has many advantages, it requires some precautions during and after irradiation such as using protective eyewear, high-speed evacuation, and a properly trained operator as an important part of laser safety. Thus, the main purpose of treating oral leukoplakia is to prevent transformation into a malignant form as the patients are mostly asymptomatic. Diode laser provides an effective technique with marked clinical improvement and high degree of patient acceptance in the management of oral leukoplakia. 

Conflict of interest: None.

REFERENCES
1. Warnakulasuriya S, Johnson NW, Van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med. 2007;36(10):575-80. [PubMed | Full Text | DOI]
2. Goyal D, Goyal P, Singh HP, Verma C. An update on precancerous lesions of oral cavity. Int J Med Dent Sci. 2013;2(1):70-5. [Full Text | DOI
3. Lodi G, Franchini R, Warnakulasuriya S, Varoni EM, Sardella A, Kerr AR, et al. Interventions for treating oral leukoplakia to prevent oral cancer. Cochrane Database Syst Rev. 2016;7:CD001829.[PubMed | Full Text | DOI]
4. Tatu R, Shah K, Palan S, Brahmakshatriy H, Patel R. Laser excision of labial leukoplakia with diode laser: A case report. Indian Journal of Research and Reports in Medical Sciences. 2013;3(4):64-6. [Full Text]
5. Bista S, Adhikari K, Saimbi CS, Agrahari B. Comparison of patient perceptions with diode laser and scalpel technique for frenectomy. J Nepal Soc Periodontol. 2018;2(1):6-8. [Full Text]
6. Gupta P, Thakur J, David CM. Excision of oral leukoplakia using 970 nm diode laser. Int J Adv Integ Med Sci. 2017;13(8):208-11. [Full Text]
7. Mohan R, Sunil MK, Raina A, Krishna K, Basu M, Khan T. Diode laser therapy of homogenous leukoplakia- A clinical study. TMU J Dent. 2017;4(3):90-2. [Full Text]
8. Bista S, Adhikari K, Saimbi CS, Agrahari B. Diode laser for lingual frenectomy. J Dent Lasers. 2018;12:74-6. [Full Text | DOI]
9. Buell BR, Schuller DE. Comparison of tensile strength in CO2 laser and scalpel skin incisions. Arch Otolaryngol. 1983;109:4657. [PubMed | DOI]
10. Natekar M, Raghuveer HP, Rayapati DK, Shobha ES, Prashanth NT, Rangan V, et al. A comparative evaluation: Oral leukoplakia surgical management using diode laser, CO2 laser, and cryosurgery. J Clin Exp Dent. 2017;9(6):e779-84. [PubMed | Full Text | DOI]


Published in: JNDA | Vol. 22 No. 1 Issue 34 Jan-Jun 2022

Simple Dental Clinic Design - Must have areas

 When designing a dental clinic, it's important to consider factors such as accessibility, efficiency, and patient comfort. Here are a few key elements to consider:

Reception and waiting area: This should be located near the entrance of the clinic and be designed to be welcoming and comfortable for patients. The number of seats should be made based on the estimated number of patients that typically visit your clinic every day.



Treatment rooms: These should be designed to optimize workflow and efficiency, with ample space for dental equipment and easy access to supplies. 

Sterilization and lab area: These areas should be designed to ensure that instruments and equipment are properly sterilized and stored. Should be separate and not easily accessible, spacious enough to accommodate an autoclave machine.

Patient amenities: Consider adding amenities such as televisions, Wi-Fi, and reading materials to help patients feel more comfortable during their visit. Proper toilets and hand-washing basins with mirrors are desirable.

Accessibility: The clinic should be accessible to the elderly and to people with disabilities and comply with relevant regulations.

It is also important to work with a professional architect and dental equipment supplier to ensure that your clinic meets all necessary regulations and has the right layout and equipment for your needs.


How to handle bargaining dental patients?

 Dealing with patients who haggle or bargain over the cost of their treatment can be challenging. Here are a few strategies you can use to handle this situation:

Be transparent: Clearly communicate the cost of treatment to the patient before any work is done. Provide them with a detailed treatment plan that includes the cost of each procedure. This can help prevent any surprises or misunderstandings after the treatment is complete.

Explain your policy: Make sure your patients are aware of your payment policy, including any fees for late payment or missed appointments.




Be empathetic: Listen to the patient's concerns and try to understand their situation. They may be facing financial difficulties or have other reasons for wanting to negotiate the price.

Offer options: If the patient is unable to pay the full cost of treatment, consider offering financing options or a payment plan.

Stand your ground: Be firm but respectful when discussing payment with the patient. If necessary, remind the patient of the value of the treatment they received and the cost of running your business.

Follow up: Make sure to follow up with the patient after the treatment to ensure that they are satisfied with the service and to remind them of the outstanding balance.

Be Professional: Be Professional at all times and avoid getting into personal arguments or confrontations with the patient.

It's important to remember that while you need to be mindful of your own financial needs, you should also strive to provide quality care and maintain positive relationships with your patients. 

How referral program could skyrocket your dental practice?

A referral program is a way to encourage current patients to refer friends and family to your clinic. Here are a few examples of how you could implement a referral program:

Offer a discount: Provide a discount on future services for patients who refer a new patient to your clinic. For example, offer $50 off their next cleaning for every new patient they refer.

Giveaway: Give a prize to patients who refer the most new patients within a certain period of time. For example, offer a gift card to a local restaurant to the patient who refers the most new patients in a month.

Loyalty rewards: Create a loyalty program that rewards patients for each referral they make. For example, offer a free cleaning for every five referrals a patient makes.

Send a thank you note: Show appreciation for patient referrals by sending a personal thank you note or a small gift.

Make it easy: Make it easy for patients to refer friends and family by providing referral cards or an online referral form.



Remember that the goal of a referral program is to make it as simple and rewarding as possible for your current patients to refer their friends and family to your clinic. These could help you to skyrocket your dental practice with a large proportion of your new patients coming through referrals. 

How to increase patients' flow in a dental clinic?

 


There are several strategies you can use to try to increase the number of patients visiting your dental clinic:

Marketing: Increase your visibility through online and offline marketing campaigns. Utilize social media, email campaigns, and local advertising to reach potential patients.

Referral program: Encourage current patients to refer friends and family to your clinic by offering incentives for successful referrals.

Special promotions: Offer special promotions, such as discounts or free consultations, to attract new patients.

Networking: Attend local networking events and conferences to connect with other dental professionals and potential patients.

Online reviews: Encourage satisfied patients to leave positive reviews on sites like Google and Yelp.

Collaboration: Partner with other medical or dental professionals in your area to cross-promote each other's services.

Improving services: Make sure that your services are up to date, with well-trained staff, clean and comfortable facilities, and cutting-edge technology.

Expand services: Offer additional services, such as cosmetic dentistry, orthodontics, or implant surgery to attract more patients.

Remember, it's important to track your progress, so you can measure the effectiveness of your efforts and make adjustments as needed.

It's also important to note that you should be compliant with the laws and regulations of your area and consult with experts to help you with the legal and financial aspects of expanding your business.

PGCEE MDS 2022: Inflammation and bleeding on probing around an implant are usually less than with natural teeth because:

 # Inflammation and bleeding on probing around an implant are usually less than with natural teeth because:
A. less plaque accumulation
B. less blood vessels
C. dense connective tissue with type III collagen
D. sulcus lining by keratinized mucosa


The correct answer is B. Less blood vessels.

Compared with an implant, the support system of a natural tooth is better designed to reduce the biomechanical forces distributed to the tooth/restoration and the crestal bone region. The periodontal membrane, biomechanical design of the tooth root and material, nerve and blood vessel complex, occlusal material (enamel) and surrounding type of bone blend to decrease the risk of occlusal overload to the natural tooth system.

Regardless of whether gingival health is relative to success, all dentists agree that the ideal soft tissue condition around an implant is an absence of inflammation. Radiographic bone loss and increased pocket depth have been correlated with sulcular bleeding. Therefore, the gingival status around an implant should be recorded and used to monitor the patient’s daily oral hygiene. However, surrounding soft tissues around implants have fewer blood vessels than teeth; therefore, inflammation is typically less around implants than around teeth.

Ref: DENTAL IMPLANT PROSTHETICS, SECOND EDITION, Carl E. Misch

PGCEE MDS 2022: Caries risk status for a DMFT score of 4 is:

 # Caries risk status for a DMFT score of 4 is:
A. Very low
B. Low
C. Moderate
D. High


The correct answer is C. Moderate.

The World Health Organization Global Data Bank (1995) shows that out of 178 countries for which data is available 25 percent were categorized as having very low levels of dental caries (DMFT 0.0 to 1.1), 42 percent as low (DMFT 1.2 to 2.6), 30 percent as moderate (DMFT 2.7 to 4.4) and 13 percent
as high (DMFT 4.5 to 6.5) and 2.1 percent countries as very high, i.e. 6.6.

Ref: A Textbook of  Public Health Dentistry, CM Marya