A RESOURCE Veterinary Practice News FOR THE ASTUTE 36 l l October 2016 TheEducationCenter PRACTITIONER www.VeterinaryPracticeNews.com A special advertising section Use CO2 laser on gingival enlargement

By Jan Bellows, DVM, Dipl. AVDC, Dipl. ABVP condition induced by the sis with a minimum amount of discomfort compared and Elizabeth McMorran, DrMedVet accumulation of plaque. to use of a scalpel. At times, the scalpel is used to For The Education Center The progression is usual- remove the bulk of the gingival enlargement and the ly slow and painless, al- carbon dioxide laser is used for hemostasis and gingi- ingival hyperplasia and hypertrophy are histo- though in advanced cases val contouring. logic terms used often to describe the clinical gingival bleeding and oral Patient safety includes protecting the endotracheal Gappearance of gingival enlargement, an increase malodor can arise, indi- tube with moist gauze and avoiding laser contact on in the size or thickness of the gingiva. cating an oral infection the surface. Operator safety includes eye protec- The term “hyperplasia” refers to an increased num- secondary to periodontal tion, a mask and a smoke evacuator. ber of normal cells in a normal arrangement, and “hy- disease (Figure 1). Prior to using laser technology, the pertrophy” describes an increase in the size of individ- n Enlargement due should practice the technique on a cadaver specimen. ual cells. Both hyperplasia and hypertrophy can only to systemic diseases and Figure 4. Peripheral odontogen- Keep in mind that the area treated typically has a thin be accurately diagnosed microscopically. When viewed inherited predisposition, tic surrounding the left layer of coagulated tissue (as little as 30 microns4) clinically without histologic confirmation, the condition such as with boxers, maxillary first along the gingival border, albeit much smaller than that is correctly termed gingival enlargement. great Danes, collies, Rott- created by an electrosurge or a diode laser. Gingival enlargement can further be classified into weilers and golden retrievers (Figure 2). Because the accumulation of plaque with the gingi- one of five categories by etiology: n Drug-induced enlargement due to medications va’s inflammatory response to this plaque is a primary n Inflammatory enlargement, the most common such as cyclosporine, calcium channel blockers (am- cause in the development of gingival enlargement, lodipine) and seizure preventives (phenytoin, phenobar- home care and frequent professional dental cleanings bital). See Figures 3-A, 3-B and 3-C. are key in keeping excess tissue formation under con- n Neoplastic enlargement. (Figure 4 demonstrates trol. After initial oral surgery, periodic touch-up proce- peripheral odontogentic fibroma surrounding the left dures to control regrowth are recommended. maxillary first premolar.) n False enlargement due to an underlying boney Techniques for CO2 Laser Gingivoplasty protuberance pushing the gingiva outward. to Treat Gingival Enlargement Gingival enlargement often produces increased pock- n Place moist gauze around the patient’s endotra- et depths, caused by augmented gingival height, but cheal tube. not attachment loss that is typical of established peri- n Place in sulcus, assessing pock- odontal disease. The resultant pseudopocket can ac- et depth (marks can be made on the gingiva using the cumulate plaque, which, if untreated, can progress to probe to define the pocket’s depth). See Figures 5-A tooth attachment loss. and 5-B. Figure 1. Inflammatory gingival enlargement in a mature spaniel This gingival enlargement may be treated by gingi- vectomy to eliminate the pseudopocket. The procedure is performed with a scalpel blade or laser, electrosur- gery or radiosurgery to remove and sculpt the gingiva. At least 2 millimeters of attached gingiva should remain after gingivectomy. The client should be in- formed that gingival hyperplasia tends to reoccur. Alternatively, extraction of the affected tooth or teeth should be considered. Another commonly used term for a gingival enlarge- Figure 2. Gingival enlargement in a boxer due to inherited predisposition ment is , a growth on the gingiva. Epulis (plural: Figure 5-A. Gingival enlargement epulides) is a general term referring to a focal growth on the labial surfaces of the left Figure 5-B. Periodontal probing of any type on the gingiva1, such as focal fibrous hyper- maxillary third and canine reveals a 5-mm pseudopocket plasia, peripheral odontogenic fibroma, acanthomatous ameloblastoma, nonodontogenic tumors, pyogenic gran- ulomas and reactive exostosis. The peripheral odontogenic fibroma (POF) is a be- nign gingival tumor of mesenchymal odontogenic ori- gin. It is most commonly believed that POF arises from the periodontal ligament.1,2 Histologically, the tumor consists of fibrous con- nective tissue separated from the surface epithelium by a layer of normal fibrous connective tissue.1 POF Figure 3-A. Gingival enlarge- Figure 3-B. An 8-mm pseudo- is also characterized by the presence of varying num- Figure 5-C. Aesculight tipless ment secondary to amlodipine pocket created by histologically ber of odontogenic epithelium rests embedded in the handpiece is used to make the Figure 5-D. Completed laser inci- administration confirmed gingival hyperplasia looser connective tissue.1,3 Finally, the tumor may initial gingival incision. sion around the tooth contain varying amounts of and other foci of collagenous matrix.1,3

Management of Gingival Enlargement and Peripheral Odontogenic Surgical management of gingival enlargement has his- torically included the use of cold steel, electrosurgery and burs to contour the gingiva’s shape while removing excess tissue. With the introduction of the surgical

carbon dioxide (CO2) laser, an additional option has be- come available to the veterinary practitioner. Figure 5-F. Pseudopocket is Laser gingivoplasty/gingivectomy allows precise Figure 5-E. Excess tissue is re- eliminated (immediate post-op Figure 3-C. Gingival enlargement secondary to cyclosporine removal of excess tissue and simultaneous hemosta- moved with a curette. appearance).

36x37 Ed Center Aesculight_.indd 36 9/20/16 10:47 AM A RESOURCE FOR THE ASTUTE TheEducationCenter PRACTITIONER October 2016 l Veterinary Practice News l 37 A special advertising section

n Calibrate the CO2 laser according to the manufac- When the periodontal pocket extends beyond the Dr. Jan Bellows is certified by the American Board of turer’s instructions. (CEJ) and the removal of Veterinary Practitioners (canine and feline) and by n Select the focal laser beam spot size (0.4-mm ce- enlarged tissue is expected to go beyond the CEJ, the American Veterinary College. He is past ramic tip or tipless handpiece) and adjust the settings gingivectomy is no longer an option. In these cases, president of AVDC and the Veterinary Dental Forum. (4 to 6 watts in continuous mode), as illustrated in Fig- periodontal surgery or extraction are options remaining. He is president of the Foundation for Veterinary Den- ure 5-C. Peripheral odontogenic fibromas (POFs) can be chal- tistry and practices in Weston, Fla. n Use the laser to remove (excise and vaporize) ex- lenging to treat given their origin from the epithelial cess gingiva and sculpt what remains without coming cell rests of Malassez within the periodontal ligament REFERENCES in contact with the enamel, cementum or . This space. In planning the surgical approach, the CO2 should result in a free gingival margin at least 2 mm laser can be used to biopsy these masses, allowing 1. Gardner DG. “Epullides in the Dog: A Review.” J Oral Pathol Med. 1996;25:32-7. coronal to the cementoenamel junction (Figure 5-D). histopathological evaluation before surgery. Ablation of 2. Daley TD, Wysocki GP. Peripheral odontogenic fibroma. Oral Surg n Use a curette to remove excess tissue (Figures 5-E these lesions with a laser is not recommended because Oral Med Oral Pathol. 1994;78:329–36. and 5-F). the result only removes the tip of the iceberg. 3. Gardner DG, Baker DC. “Fibromatous Epulis in Dogs and Peripheral Odontogenic Fibroma in Human Beings: Two Equivalent In cases of drug-induced gingival enlargement, the Following CO2 laser treatment of gingival enlarge- Lesions.” Oral Surg Oral Med Oral Pathol. 1991;71(3):317-21. medication causing the problem should be changed ment and biopsy of POFs, nonsteroidal anti-inflamma- 4. Wilder-Smith P, Arrastia AM, Liaw LH, Berns M. “Incision Properties and Thermal Effects of Three CO Lasers in Soft to one that does not induce gingival enlargement. tory and narcotics should be administered to control 2 Tissue.” Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995; Laser treatment of the enlarged gingival tissues is post-surgical pain and discomfort. Two weeks after 79(6):685-91. similar to the technique described above (Figures oral surgery, home care in the form of brushing or wip- 6-A, 6-B and 6-C). ing should commence. l RECOMENDED READING 1. Lewis JR, Reiter AM. “Management of Generalized Gingival Enlargement in a Dog: Case Report and Literature Review.” J Vet Dent. 2005;22(3):160-69. 2. Wiggs RB, Lobprise HB. Clinical oral pathology. In: Wiggs RB, Lobprise HB, eds. Veterinary Dentistry: Principles and Practice. Philadelphia: Lippincott-Raven; 1997:104-39. 3. Bellows J. “Laser Use in Veterinary Dentistry.” Vet Clin Small Anim. 2002;32:673-92.

This Education Center article was underwritten by Figure 6-A. A 9-mm pseudo- Figure 6-B. Scalpel blade is used Aesculight of Woodinville, Wash., the manufacturer pocket surrounding the right to excise enlarged gingiva sur- Figure 6-D. One month post-op Figure 6-C. Aesculight carbon diox- of the only American-made CO2 laser. mandibular canine rounding right maxillary canine. ide laser is utilized to sculpt tissue. appearance

36x37 Ed Center Aesculight_.indd 37 9/14/16 1:42 PM