CO2 and diode lasers-combined excision of a recurrent pyogenic granuloma

Pyogenic granuloma (PG) is a type of neoplastic-like inflammatory fibrous hyperplasia and often seen on the gingiva of those patients with poor oral hygiene.¹ PG is one of the most common inflammation/reactive biopsied lesions in oral cavity.² Laser is proposed as an alternative treatment to replace the conventional surgical excision. Laser assisted-excision has many benefits such as ease of soft tissue ablation, adequate coagulation, reduced postoperative pain, and short healing duration.³ However, little is focused on esthetic appearance after PG removal. This case report presented the combination of CO2 and diode lasers for a recurrent PG to achieve the esthetic profile simultaneously.

A 24-year-old female was referred to Department of Stomatology, Chung Shan Medical University Hospital for removal of a recurrent painless and easily-bleeding gingival mass over teeth 31 and 32 interproximal area (Fig. 1A). The purple mass was approximately 2 × 2 cm in diameter at the buccal side, which was covered by plaque and calculus with 5 mm periodontal pocket. The patient's past medical and dental histories were unremarkable. The initial therapy was performed with oral hygiene instruction, scaling, and root planning to reduce gingival inflammation. First, CO2 laser (Opelaser PRO II, Yoshida, Tokyo, Japan) was used to separate the mass away from the gingival margin at least 1 mm. The excised tissue was sent for histopathological analysis. Then, the residual portion was ablated and vaporized carefully to achieve the scalloped gingival contour with the Dental Laser D5 (Doctor Smile, Brendola, Italy). All the procedures were performed according to the manufacturer's instructions.

Figure 1.

Clinical and histopathological photographs of our pyogenic granuloma. (A) An erythematous soft tissue mass at the buccal interdental papilla between the teeth 31 and 32. (B) Histopathological microphotograph showing a pyogenic granuloma with many small-sized blood vessels and an inflammatory cell infiltrate in a granulation tissue. (C) 2.5 months after removal of the lesion, a mild gingival recession was observed. (D) After 4-month followed-up, clinically healthy gingival profile was noted at the buccal aspect.

Postoperative oral hygiene was instructed by using chlorhexidine mouthwash rinse. Histological examination revealed many small-sized blood vessels and an inflammatory cell infiltrate in a granulation tissue (Fig. 1B). These histopathological findings confirmed the diagnosis of a PG. Post-excisional healing was uneventful (Fig. 1C). After 4-month follow-up, the gingival wound healed completely with healthy pink color (Fig. 1D).

The type of laser used in the surgery is very important. CO2 laser, due to its high water absorption and less penetration compared to diode lasers, is suitable tool for cutting.⁴ Therefore, CO2 laser was firstly used to establish a good operating visibility and efficiency.⁴ Diode laser with the wavelengths (810–980 nm) is poorly absorbed by teeth and bones and thus soft tissue surgeries can be safely done close to tooth structure avoiding damage by ablation/vaporization procedures.⁵ Finally, the residual tumor tissue was removed by diode laser to achieve a biologic gingival contour that would be good for gingival health maintenance and esthetics. In this case report, the combination of CO2 and diode laser could be successfully used to excise the PG and satisfy the patient's esthetic request. Creating the proper gingival morphology could provide easy oral hygiene maintenance and further diminish the irritants of dental plaques to prevent recurrence. Although this is a case report, the technique we use may be clinically relevant. However, due to the high recurrence rate of the PG, long-term follow-up is highly recommended.

Conflicts of interest

The authors have no conflicts of interest relevant to this article.