Long-term effects of Ag-containing alloys on mucous tissue present in biopsy samples

Novel flapless esthetic procedure for the elimination of extended gingival metal tattoos adjacent to prosthetic teeth: Er:YAG laser micro-keyhole surgery

PURPOSE

This article describes a novel, minimally invasive procedure called Er:YAG laser micro-keyhole surgery (EL-MIKS) that removes metal or amalgam tattoos in the gingiva adjacent to prosthetic teeth without gingival deformity and recession. We aimed to evaluate the clinical efficacy of EL-MIKS for removing metal tattoos and present its long-term treatment outcomes.

METHODS

The EL-MIKS procedure consists of several steps that are all performed under a microscope. First, a micro-keyhole (1-2 mm diameter) was prepared using an Er:YAG laser in the center of the metal pigmentation. The connective tissue was evaporated in the deep layer, where metal debris was deposited. Second, within the accessible range, the irradiation angle was changed in various directions to ablate the metal pieces and discolored connective tissue without enlarging the keyhole. Finally, after blood filled the space created by the tissue evaporation, the surface of the blood clot at the entrance of the micro-keyhole was thermally coagulated with defocus laser irradiation. Pigmentation that could not be successfully removed from a single micro-keyhole was treated by forming new micro-keyholes at a distance of 3 mm or more from each previously created hole. Depigmentation over an extended area was completed over a few sessions every 4 weeks without gingival recession after surgery.

CONCLUSIONS

EL-MIKS, a novel depigmentation technique, was able to successfully remove an extended area of metal tattoos in the gingiva using a simpler, easier, and less invasive procedure than conventional periodontal plastic surgery. Esthetic restoration was successfully achieved without postoperative alteration of the gingival contour.

Clinical and Forensic Aspects of the Different Subtypes of Argyria

Argyria encompasses the different cosmetic alterations that can develop if enough silver particles deposit in a specific tissue, typically in the skin, ranging from localized dark-blue macules to a generalized slate-gray/bluish tinge following systemic absorption. This work aims to fully review the state of the art regarding pathophysiology, diagnosis, treatment, and relevant clinical and forensic features of argyria. Argyria has been diagnosed in a wide range of ages, both sexes and varied ethnicities, with no known individual predisposing factors. Ultraviolet radiation with subsequence increases of melanin production aggravates the discoloration due to a reduction in the silver deposits. Physical examination and silver exposure in the anamnesis can be highly suggestive of the diagnosis, but a histopathological analysis with Energy-Dispersive X-ray Spectroscopy is required to unequivocally determine the discoloration etiology. Safe and effective treatment has only been accomplished with laser techniques, though only a few cases have been reported and with limited follow-up time. In conclusion, argyria typically has an occupational or iatrogenic etiology. It should be suspected when a patient presents with typical skin or eye lesions. A seemingly viable treatment modality, with laser technology, is finally within the horizon.

A novel minimally-invasive approach for metal tattoo removal with Er:YAG laser

OBJECTIVE

Few effective and established treatment methods can remove gingival metal or amalgam tattoos. With this case series, we aimed to demonstrate the use of a novel minimally invasive technique to remove metal tattoos using an erbium-doped yttrium aluminum garnet (Er:YAG) laser.

MATERIALS AND METHODS

We retrospectively collected clinical data from 18 patients who had undergone Er:YAG laser treatment to remove metal tattoos. Minimal gingival ablation using an Er:YAG laser directed towards the pigmented area was performed, which exposed metal debris within the connective tissue that was carefully removed. A dental microscope was employed to identify the metal debris, for accurate irradiation, and to minimize wounding by reducing invasion. Postoperative gingival color and morphology, and visual analog scale as a patient-reported outcome assessing postoperative pain were evaluated.

RESULTS

All patients' metal tattoos were removed completely and safely during short procedures. Considerable esthetic improvements and favorable wound healing were achieved with almost no postoperative pain or complications.

CONCLUSION

The findings from this case series suggest that this novel minimally invasive therapy for metal tattoo removal that involved the Er:YAG laser is effective and safe, is associated with successful outcomes, and contributes greatly to patients' esthetic satisfaction.

CLINICAL SIGNIFICANCE

Metal tattoo removal using an Er:YAG laser safely and successfully improved gingival esthetics. This novel technique is much simpler and less invasive than conventional periodontal plastic surgery, and it may be more reliable regarding esthetic gingival improvements as it is associated with favorable wound healing, and it could offer significant benefits to patients by alleviating physical and mental stresses via reduced chair time and postoperative pain.

The mechanism of gingiva metallic pigmentations formation

The occurrence of blue-grey areas in the soft tissue represents one of the problems affecting patients whose teeth have been restored using metallic materials. It is generally accepted that it is caused by mechanical penetration of a metallic material into the soft tissue. Several facts indicate that this mechanism is not general. The aim of the study was to determine an alternative mechanism of the origin of pigmentations, based on the corrosion interaction of metallic materials used in prosthodontics with the oral environment. The study was comprised of an analysis of pigment particles, determination of exposure conditions of metallic materials in vivo and laboratory evaluation of corrosion properties of the studied materials. Particles containing silver, sulphur and/or selenium could be seen in ultra-thin sections in the lamina propria gingivae. Comparison of the corrosion laboratory results with the results of in vivo measurements indicated the intensification of corrosion under these conditions. Amalgams and silver-containing alloys used for teeth restorations may release silver under the conditions of the oral cavity. The formation of soluble silver compounds in the sulcular area or in a crevice between the crown and the cast post-and-core reconstruction facilitates their transport to the soft tissue and subsequent deposition.

Local adverse effects of amalgam restorations

Amalgam has been used for the restoration of teeth for well over 100 years, and is the most successful of the direct restorative materials with respect to longevity. Despite the increasing use of tooth-coloured materials, with advantages of aesthetics and adhesion, amalgam is one of the most widely used dental restorative materials. One of the principal disadvantages of amalgam, apart from aesthetics, is that it may have adverse biological effects, both locally and systemically. Locally, it can cause an erythematous lesion on the adjacent oral soft tissues (tongue and buccal mucosa), and systemically free mercury in the amalgam may give rise to a hypersensitivity reaction. The purpose of this paper is to review the literature concerning the local adverse reactions to dental amalgam. The focus will be on the reactions of the oral mucosa, and brief consideration will be given to laboratory cytotoxicity of dental amalgam and its components, and to the 'amalgam tattoo'.