Carbon dioxide laser evaporation of leukoplakia of the lower lip: a retrospective evaluation

Developmental synergism in the management of oral potentially malignant disorders

Oral potentially malignant disorders (OPMDs) are associated with an increased risk of occurrence of cancers of the oral cavity or lips. The unifying theme of OPMDs is their potential risk for cancer development. Therefore, the primary objective of the management should be to prevent carcinogenesis. Beyond diagnosis, current strategies for the management of OPMDs predominantly include non-surgical and surgical interventions and a "watch-and-see" approach, such as disease monitoring or surveillance, and preventive strategies. Though no optimal clinical treatment has gained universal approval for reducing or preventing malignant development of OPMDs. Therefore, an urgent need exits for improved treatment properties and effective predictive markers for OPMDs treatment. This review aims to outline recent synergism regarding to the management of OPMDs. Developing new technologies and improved application parameters to promote the treatment efficacy and a novel management prescription approach to OPMDs are proposed.

Lasers in Maxillofacial Surgery - Review of Literature

The availability of different wavelengths of lasers has created a surgical panacea in the last decade and laser technology has become the standard of care for many oral and maxillofacial surgical procedures. In this article, based on literature search, we have reviewed the usage of laser in maxillofacial surgery based on the current evidence available on laser-assisted maxillofacial surgery, in PubMed database.

Laser excision of oral leukoplakia: Does it affect recurrence and malignant transformation? A systematic review and meta-analysis

Oral leukoplakia (OL) is a white lesion with high potential of recurrence and malignant transformation. The variable clinical and histopathological features of OL may potentially impact both treatment and prognosis. Current literature shows that post treatment rates of recurrence and malignant transformation vary widely. The use of surgical lasers have been proposed with the objective of improving outcomes. We performed a systematic review and a comprehensive meta-analysis dedicated to pooling the rates of recurrence and malignant transformation of OL lesions treated using the main types of surgical lasers available. Scopus, MEDLINE/PubMed, and Embase were searched electronically. A total of 36 articles met the inclusion criteria. Selected studies included OL lesions that were treated by evaporation or excision using Nd:YAG laser, Er:YAG laser, CO2 laser, KTP laser, or diode laser. The results of this systematic review and meta-analysis suggest that surgical laser excision of OL may decrease recurrence rates but have no effect on the malignant transformation of OL when compared with conventional treatments.

Type of surgical treatment and recurrence of oral leukoplakia: A retrospective clinical study

BACKGROUND

Oral leukoplakia (OL) is the most typical potentially malignant disorder of the oral mucosa. We aimed to evaluate the clinical outcome of oral leukoplakia treated with several types of lasers and with the use of quantic molecular resonance (QMR) lancet, in terms of recurrence rate.

MATERIAL AND METHODS

Eighty-seven previously untreated OL (52 occurring in females and 35 in males, mean age of 59.4 ± 13.9 years) were consecutively submitted to surgical treatment at University Hospital of Parma, Italy, and Hospital de Valongo, Portugal, (1999 to 2012). Interventions were subclassified into 5 groups according to the instrument used for the surgical removal of OL (cold blade - 17; Nd:YAG 1064nm laser - 14; Er:YAG 2940nm laser - 33; CO2 10600nm laser - 15; and QMR scalpel - 8). The mean follow-up period after treatment was 21.6 months (range 1-151 months). The outcome of treatment was scored through the same clinical protocol in the two participating units. Statistical analysis were carried by univariate analysis using chi-square test (or Pearson's test when appropriate).

RESULTS

Recurrences were observed in 24 cases of OL (27.6%). Malignant transformation occurred in one patient (1.1%) after a period of 35 months. Statistical comparison of the 5 surgical treatment modalities showed no differences in clinical outcomes nor in the recurrence rate of OL. However, when Er:YAG laser group was compared with traditional scalpel, a significantly better outcome in cases treated with Er:YAG laser (P = 0.015) was highlighted.

CONCLUSIONS

Our results suggests that Er:YAG laser could be a promising option for the treatment of OL.

Evaluation of Different Laser-Supported Surgical Protocols for the Treatment of Oral Leukoplakia: A Long-Term Follow-Up

PURPOSE

The aim of this study was to evaluate the long-term success rate of oral leukoplakia treatments by using different laser-supported surgical protocols.

PATIENTS AND METHODS

Overall, 2347 diagnosed homogeneous oral leukoplakias were treated with CO₂ laser and were included in this study. Different surgical protocols (P) were used: P1 (SV = superficial scanning) was a complete superficial vaporization of the leukoplakia by a scanning mode in two passages respecting an overlapping. Only the visible white area was treated in one surgical session independently of the lesion size. P2 (CR1x1) was a complete excision of the lesions until a tissular depth of 1 mm and 1 mm of surrounding healthy-like tissue were attained. The visible white area was treated in one surgical session independently of the lesion size. P3 (CR1x3) was a complete excision of the lesions until a minimum tissue depth of 1 mm and 3 mm of surrounding healthy-like tissue were obtained. The visible white area was treated in one surgical session independently of the lesion size. P4 (PR1x3) was similar to the third one, but for patient comfort, the large lesions of leukoplakias (lesion size higher than 20 mm), the complete surgical excision of the leukoplakia was performed in multiple sessions that were spaced by 1 month (partial surgical removal of 10 mm per session). All patients were recalled at 2 and 8 weeks after surgery, and then every 2 months during the first year, every 4 months during the second year, and once a year for the follow-up period of 6 years. A biopsy was done once a year during the follow-up period in the surgical site when needed. The control consisted of checking the nature and the aspect of the healed mucosa to exclude an eventual recurrence of leukoplakia.

RESULTS

The percentage of permanent success after 6 years of follow-up was 5.7%, 69.7%, 97.8%, and 71.9%, respectively, for the first surgical protocol (SV), the second (CR 1 × 1), the third (CR 1 × 3), and the fourth (PR 1 × 3). The appearance of malignant transformation after laser treatment (during the follow-up period of 6 years) was 20%, 1%, and 0.2%, respectively, for the groups treated by the following protocols: 1 (SV), 2 (CR 1 × 1), and 4 (PR 1 × 3). Only in the third group CR1x3, no dysplasia or malignant transformation was noted. On the contrary, the appearance of malignant transformation in failed treated cases was 21.21% for the protocol 1 (SV), 3% for the protocol 2 (CR 1 × 1), and 0.6% for the protocol 4 (PR 1 × 3).

CONCLUSIONS

The results of this long-term follow-up of treated patients with oral homogeneous leukoplakias pointed out that the surgical laser protocol respecting the complete excision of leukoplakias, in one session, by the removal of a minimum of 1 mm in lesion depth and 3 mm of surrounding healthy-like tissues (CR 1 × 3) offers significantly the highest success rate.

Oral leukoplakia treatment with the carbon dioxide laser: A systematic review of the literature

We conducted a systematic review of the literature to evaluate treatment of oral leukoplakia with the carbon dioxide (CO2) laser. A comprehensive search of studies published between 1981 and 2015 and listed in the PubMed (National Library of Medicine, NCBI) database yielded 378 articles which were screened in detail. Relevant studies were selected according to predetermined inclusion and exclusion criteria. A total of 33 articles met the final inclusion criteria and were analysed in detail in accordance with the PRISMA-P statement. These full-text papers were classified as synopses (n = 7), recurrence and malignant transformation studies (n = 17), comparative studies between CO2 laser and cold knife surgery (n = 3) and studies evaluating the efficacy of CO2, Nd:YAG and KTP lasers. According to the literature the CO2 laser is the workhorse of oral leukoplakia treatment due to its effectiveness and low associated morbidity. However, randomized clinical trials are needed to compare CO2 laser with other lasers. The results of our systematic review showed that there is no consensus regarding the factors involved in higher recurrence and malignization rates, so further studies are needed.

CO2 laser of oral dysplasia: clinicopathological features of recurrence and malignant transformation

The use of the CO(2) laser in the management of oral dysplastic lesions has become a more common practice. Very few studies have evaluated recurrence, residual disease malignant transformation, and overall outcome in patients undergoing such a procedure. In this prospective study, a total of 123 oral dysplastic lesions from 77 consecutive patients were treated with the CO(2) laser (resection and/or ablation). The average age was 58 ± 4.8 years. The patients' recovery was uneventful and no complications were reported. Comparisons with the clinical and histopathological features and rate of recurrence as well as malignant transformation were made. The patients were followed-up for a mean of 6.4 years, and biopsies taken in case of changes suggestive of malignant development. Homogenous leukoplakias were identified in 31 patients, non-homogenous leukoplakias in 34 patients, whereas 12 patients had erythroplakias. Ex- and life-long smokers formed 88.3% of the recruited patients. While people who currently smoke and drink formed 55.8% of the cohort. Erythroplakias were solely identified in heavy life-long smokers. The most common identified primary anatomical locations were the lateral border of tongue, floor of mouth, and buccal mucosa. Moderate dysplasia was identified in 42 patients while 18 patients had severe dysplasia. Laser resection margins in selected cases (68 patients) were clear in 53 and showed mild-moderate dysplasia in the involved margins. The rate of recurrence had no significant association with the location but the severity of epithelial dysplasia. The rate of first recurrence after laser surgery was approximately 19.5%. Malignant transformation was observed in eight patients (10.4%), in the tongue and the floor of mouth. Recurrence and malignant transformation was mainly identified in erythroplakias and non-homogenous leukoplakias. Laser resection/ablation is recommended for oral dysplasia to prevent not only recurrence and malignant transformation but also postoperative oral dysfunction encountered by other conventional modalities.

Treatment of oral leukoplakia with carbon dioxide and potassium-titanyl-phosphate lasers: a comparison

PURPOSE

To determine whether the treatment of oral leukoplakia with potassium-titanyl-phosphate (KTP) lasers versus CO(2) lasers results in lower recurrence rates.

MATERIALS AND METHODS

Retrospective data were collected from the records of 30 patients (mean age 75.6 years) with 35 primary oral leukoplakia who had their lesions ablated by KTP laser, and 45 patients (mean age 59.9 years) with 59 primary oral leukoplakia who had CO(2) laser treatment. The recurrence rates of lesions between these 2 groups was then compared.

RESULTS

A statistically significant (P = .049) reduction in recurrence rates for those patients treated with KTP lasers versus CO(2) lasers was found.

CONCLUSION

The use of KTP lasers for the treatment of oral leukoplakia may result in lower recurrence rates than when using CO(2) lasers.

A new modality in the treatment of actinic cheilitis using the Er:YAG laser

BACKGROUND

Cheilitis is a precancerous skin lesion most often affecting the lower lip. We describe a technique in which this disorder can be treated using Er:YAG laser vaporization. The Er:YAG laser wavelength at 2940 nm lies in a very strong water absorption peak; tissue interaction results mainly in vaporization with minimal heat conduction to adjacent tissue.

OBJECTIVE

To evaluate the efficacy and outcome of a new modality in the treatment of actinic cheilitis with the Er:YAG laser.

METHODS

Between 2002 and 2005, 12 patients with actinic cheilitis were treated at our institute with the Er:YAG laser. All patients were cured with no recurrence to date, and none suffered postoperative complications.

RESULTS

Patients were men and women aged between 37 and 71 years. The healing duration varied from 7 to 30 days (mean 22.33+/-6.91 days) and the follow-up ranged from 8 months to 3 years (mean 23.16+/-9.48 months). No recurrences were detected in our study.

CONCLUSION

Using the Er:YAG laser provides accurate tissue ablation, giving a very satisfactory cosmetic result, with a short healing period, no lip deformity and no sensation loss.

Long-term treatment outcome of oral premalignant lesions

The purpose of the present retrospective study was to learn the long-term outcome of oral premalignant lesions, leukoplakia and erythroplakia, with or without surgical intervention and to relate the outcome to factors supposed to be significant for malignant development including clinical type, demarcation, size, site, presence of epithelial dysplasia, smoking and surgery. A total of 269 lesions in 236 patients were included. Ninety-four lesions were surgically removed, 39 lesions (41%) being homogenous and 46 (49%) non-homogenous leukoplakias whereas nine (5%) were erythroplakias. Seventy-three percent of the lesions were associated with tobacco habits. The mean size of the lesions was 486 mm(2), and 71% of the lesions showed a degree of epithelial dysplasia. After excision the defects were closed primarily by transposition of mucosal flaps or they were covered by free mucosal or skin grafts. A few defects were left for secondary healing. After surgical treatment the patients were followed (mean 6.8 yrs, range 1.5-18.6 yrs), and new biopsies taken in case of recurrences. One hundred and seventy five lesions had no surgical intervention, 149 lesions (85%) being homogenous and 20 (11%) non-homogenous leukoplakias, and 6 (3%) erythroplakias. Eighty-one percent of the lesions were associated with smoking. The mean size of the lesions was 503 mm(2) and 21 of the lesions (12%) exhibited epithelial dysplasia. Sixty-five lesions were not biopsied. These patients were also followed (mean 5.5 yrs, range 1.1-20.2 yrs), and biopsies taken in case of changes indicative of malignant development. All patients were encouraged to quit smoking and candidal infections were treated. The possible role of different variables for malignant development was estimated by means of logistic regression analysis. Following surgical treatment 11 lesions (12%) developed carcinoma after a mean follow-up period of 7.5 yrs. Non-homogenous leukoplakia accounted for the highest frequency of malignant development, i.e. 20%, whereas 3% of the homogenous leukoplakias developed carcinomas. Surgically treated lesions with slight, moderate, severe and no epithelial dysplasia developed carcinoma with similar frequencies, i.e. 9-11%. Without surgical intervention 16% of the 175 lesions disappeared whereas seven lesions (4%) developed carcinoma after a mean observation period of 6.6 yrs. The highest frequency of malignant development (15%) was seen for non-homogenous leukoplakias, this figure being 3% for homogenous leukoplakias. Fourteen percent of lesions with slight epithelial dysplasia developed malignancy and 2% of lesions with no dysplasia showed malignant transformation. Logistic regression analysis showed a seven times increased risk (OR = 7.0) of non-homogenous leukoplakia for malignant development as compared with homogenous leukoplakia and a 5.4 times increased risk for malignant development for lesions with a size exceeding 200 mm(2). No other examined variables including presence of any degree of epithelial dysplasia, site, demarcation, smoking and surgical intervention were statistically significant factors for malignant development.

The results of CO2 laser surgery in patients with oral leukoplakia: a 25 year follow up

Oral leukoplakia is an important premalignant lesion of the oral mucosa. We treat this lesion prophylactically with CO2 laser evaporation. In the period from 1976 to 2001, a group of 200 patients with 282 oral leukoplakias were treated by CO2 laser evaporation. In a follow up period of 1-219 months (mean 52), 251 treated leukoplakias (89.0%) did not show a recurrence. Twenty eight (9.9%) local recurrences were observed in 5 to 168 months after treatment. Three (1.1%) squamous cell carcinoma, occurred in the treated area respectively 7, 17 and 19 month after CO2 laser evaporation. This large study with a long follow up shows that laser treatment is a good prophylactic treatment for oral leukoplakia.

Laser surgery as a treatment for oral leukoplakia

Various treatment procedures for oral leukoplakia have been reported. However, after some treatments, oral leukoplakia show recurrence and/or malignant transformation, even following complete resection. Furthermore, patients with oral leukoplakia may develop new lesions in other oral cavity locations. Laser surgery for oral mucosal lesions has been reported to have many advantages, and it is widely used in the treatment of oral leukoplakia. In previous studies, recurrence and malignant transformation from the lesion have occasionally been observed following laser surgery. We reviewed the records of oral leukoplakia patients treated with laser surgery to assess its clinical usefulness. It has been reported that the rate of recurrence was 7.7-38.1%, while malignant transformation was 2.6-9% for oral leukoplakia treated with laser surgery. In the present study, there was 29.3% recurrence and 1.2% malignant transformation after laser surgery. This was similar to previous findings. This suggests that non-homogeneous leukoplakia on nonkeratinized epithelia, i.e. the tongue mucosa has a high risk for malignant transformation, so lesions should be excised after detecting abnormal epithelia using vital tissue staining. The wound healing process after laser surgery was satisfactory and no significant complications were observed. Management of oral leukoplakia prevents not only recurrence and malignant transformation, but also postoperative dysfunction: laser surgery is an excellent procedure that is able to overcome these problems.

Oral lichen planus: progress in understanding its malignant potential and the implications for clinical management

Oral lichen planus (OLP) is an inflammatory lesion that has malignant potential, but few cases of OLP progress to malignancy. A diagnosis of OLP should be confirmed on the basis of historical, clinical, and histologic data. The presence of dysplasia in an OLP-like lesion increases the risk of malignant transformation, mandating management and close follow-up. A molecular assessment of OLP may provide the best evidence of malignant risk and will likely become available for clinical use. In addition, exfoliated cells may be examined for loss of heterozygosity and may become a valuable clinical tool for patient follow-up. The treatment of OLP should include elimination of tissue irritants and recurring exposure to oral carcinogens. If OLP is symptomatic, appropriate treatment with immunosuppressive medications, particularly corticosteroids, should be undertaken. For lesions with dysplastic changes, management may include attention directed to the inflammatory change and follow-up biopsies to assess residual histologic changes that may represent dysplasia. Dysplastic OLP may be best treated as other oral dysplastic conditions; thus, regular, more frequent follow-up is required.