Treatment of gingival fibromas using CO2 laser and electrosurgery in a patient with tuberous sclerosis
1. Assistant Clinical Professor of Dermatology, Department of Dermatology, University of California Davis Medical Center, Sacramento, CA. email@example.com
A 10-year-old boy with a history of tuberous sclerosis was sent for evaluation of numerous papules on his lower gum area. The parent was concerned that the lesions were interfering with oral hygiene. A diagnosis of oral fibromas was made and treatment options of gingivectomy or electrosurgery combined with carbon dioxide laser were described to the patient and his parent. Therapy with electrocautery and a pulsed carbon dioxide laser was decided on and utilized. We describe for the first time the combination of electrosurgery and carbon dioxide laser as a treatment method for oral fibromas. A short review of the literature regarding diagnosis and treatment is included with this report.
Oral angiofibromas are a minor criteria for the diagnosis of tuberous sclerosis. Traditional treatment for these lesions has been gingevectomy. Treatment options for these lesions have not been well studied. We report a patient treated with a combination of electrosurgery and carbon dioxide laser.
Report of Case
A 10-year-old boy was sent for evaluation of numerous papules on his lower gum area (Fig. 1). A shave biopsy from the mandibular gingiva, which was performed prior to consultation, confirmed the lesions to be angiofibromas (Fig. 2). The parent was concerned that the lesions were interfering with oral hygiene. Treatment options of gingivectomy and electrosurgery combined with carbon dioxide laser were described to the patient and his parent. The parent decided on treatment with electrosurgery and carbon dioxide laser. After obtaining anesthesia using intraoral mandibular nerve blocks, the biggest lesions were debulked using electrocautery. The debris was then wiped away using sterile gauze pads. The carbon dioxide laser was then used to ablate the residual remaining lesions with the following treatment parameters: 2-3 passes, 18 percent overlapping pulses, 250 mj/sec, 31.2 W, shape #3, size 1. The patient tolerated the procedure well and was completely healed nine days following therapy (Fig. 3). There was no evidence of gum recession or damage to the teeth enamel. The patient was seen in follow-up 24 months following the procedure with only minimal recurrence of the lesions (Fig. 4).
Tuberous sclerosis (Bourneville disease) is an autosomal dominant disease characterized by the triad of epilepsy, low intelligence and facial angiofibromas (adenoma sebaceum) . However, the full triad of symptoms is present in only a minority of patients. Tuberous sclerosis has an estimated prevalence of 1:5800 . Major features of the disease include: facial angiofibromas, ungual or periungual fibromas, hypomelanotic macules, shagreen patch (connective tissue nevus), multiple retinal nodular hamartomas, cortical tubers, subependymal nodules, subependymal giant cell astrocytomas, cardiac rhabdomyomas, lymphangioleiomyomatosis, renal angiomyolipomas . Minor criteria for the disease include dental enamel pits, hamartomas, rectal polyps, bone cysts, cerebral white matter, radial migration lines, gingival fibromas, nonrenal hamaroma, retinal achromic patch, confetti ski lesions, multiple renal cysts.
Gingival fibromas associated with tuberous sclerosis have been documented in only a few case reports, but they are considered a minor criterion for the diagnosis of the disorder. Their prevalence in patients with tuberous sclerosis is unknown. The differential diagnosis of these papules includes: gingival fibrous nodule, papilloma, focal epithelial hyperplasia, fibroma, gingival cyst, multiple hamartomas, and exostosis.
Treatment regarding oral angiofibromas has not been well studied . However, there are many descriptions in the literature detailing the use of CO2 laser for facial and periungual fibromas [6-13]. The CO2 laser is used in oral medicine most often in the setting of phenytoin, or cyclosporine induced gingival overgrowth [14-17]. The laser has the following advantages in the setting of oral surgery: hemostasis, reduced postoperative swelling, reduced bacterial concentration at the surgery site, reduced need for suturing, quicker healing, and less post operative pain [14, 17-27].
Our case adds to the sparse literature on treatments for oral angiofibromas. The use of electrosurgery and carbon dioxide laser ablation is ease to perform and appears to be effective and well tolerated. It should be considered as a treatment option for patients with this disorder.
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