|Year : 2017 | Volume
| Issue : 4 | Page : 256-260
Cryosurgery for the treatment of oral leukoplakia: Satisfying or not?
Varun Kumar1, Divye Malhotra2, Ashish G Mular3, Swapnil Sachan4, Deepali Sharma4
1 S.P. Dental and Maxillofacial Trauma Centre, Jammu, Jammu and Kashmir, India
2 Department of Oral and Maxillofacial Surgery, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India
3 Department of Oral and Maxillofacial Surgery, Saraswati Dhanwantari Dental College and Hospital, Parbhani, Maharashtra, India
4 Department of Oral and Maxillofacial Surgery, Divya Jyoti College of Dental Sciences and Research, Modinagar, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||1-Dec-2017|
S.P. Dental and Maxillofacial Trauma Centre, Sapna Complex, Trikuta Nagar Extension, Jammu - 180 012, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Oral leukoplakia is a common precancerous lesion that may transform into squamous cell carcinoma. Epidemiology reports available from studies conducted in different parts of India reveals the prevalence rate of leukoplakia from 0.2% to 8%. The malignant transformation rates of oral lesions are reported to be 1%–7% for homogenous thick leukoplakia, 4%–15% for granular or verruciform leukoplakia, and 18%–47% for erythroleukoplakia. Context: Although there are many treatment options ranging from the simple discontinuation of the tobacco habits in mild cases to more aggressive approaches like surgical excision to exceedingly sophisticated techniques such as laser surgery, and photodynamic therapy. Cryosurgery has also been implemented as an effective treatment for precancerous lesions of the oral cavity and has shown to have various advantages over the other procedures such as minimal/no pain, less swelling, no bleeding, simplicity, versatility, and low cost. Aims: To check whether cryosurgery can provide as good results as those obtained by today's latest and super sophisticated surgical modalities. Settings and Design: Experimental observational study. Materials and Methods: In this study, 25 lesions of different types of leukoplakia, in 19 patients were treated using closed type cryosurgical system. Statistical Analysis Used: Chi-square test and independent t-test. Results: Complete regression was achieved in 22 (88%) lesions, 2 (8%) cases resulted in incomplete regression thus were retreated and complete regression. 1 (4%) subject did not report for follow up after the 7th postoperative day. Conclusions: In this study, results were found to be very promising but more research in this field is required as the sample size in this study was small.
Keywords: Cryosurgery, oral leukoplakia, precancerous
|How to cite this article:|
Kumar V, Malhotra D, Mular AG, Sachan S, Sharma D. Cryosurgery for the treatment of oral leukoplakia: Satisfying or not?. Indian J Dent Sci 2017;9:256-60
|How to cite this URL:|
Kumar V, Malhotra D, Mular AG, Sachan S, Sharma D. Cryosurgery for the treatment of oral leukoplakia: Satisfying or not?. Indian J Dent Sci [serial online] 2017 [cited 2023 Nov 28];9:256-60. Available from: http://www.ijds.in/text.asp?2017/9/4/256/219629
| Introduction|| |
The term “Cryosurgery” is derived from the Greek word “Kryos,” that means “frost,” thus literally meaning “frost surgery.”,, It is the controlled and targeted destruction of diseased tissue by application of extreme cold temperature. To be more precise, this method is based on the therapeutic use of cytotoxic effects of extreme cold on the living tissues to obtain their destruction., Various terms which have been used in literature for this technique are cryotherapy, cryocongelation, cryocautery , cryogenic surgery, cryoablation and cryosurgery., Currently, cryotherapy refers to various treatments aimed at lowering the body surface temperature without tissue destruction, whereas in cryosurgery diseased tissues are destroyed. This study was conducted to explore the benefits and inadequacies of cryosurgery in the management of various types of oral leukoplakia [Table 1].
| Materials and Methods|| |
25 lesions in 19 patients (16 males and 3 females) were treated in this study using closed type of cryosurgical system (based on “Joule-Thompson” principle) with a set of four cryoprobes of different size and shapes. Nitrous oxide gas was used as cryogen [Figure 1]. Types of tobacco habits associated and their status after counseling were noted [Table 2]. Physical features of the lesions such as site, dimensions, and surface characteristics along with general clinical parameters like linear mouth opening measurement were recorded. Biopsy and histopathological conformation of the lesions was done. The cryosurgery procedure was performed by direct application of probe of suitable size onto the lesion [Figure 2]. The cryoprobe was precooled (before application to the tissues) by letting the gas flow through the probe for 5 seconds. Cryoprobe was fixed in place as ice formation occurred and was not moved until thaw begun. Large lesions were managed by multiple overlapping applications till the entire disease area could be treated. For thick lesions, the pressure was applied to depress the probe to increase the depth of the ice ball [Figure 3]. For superficial lesions either probe was placed gently or slight traction was applied. In case of extensive or multifocal leukoplakia, the toluidine blue test was performed to establish the priority of one area over another. For all lesions, a single session was given in which two cycles of the freeze of 1½ min with thaw of 1½ min was given. The lesion after treatment with cryosurgery was left as such and tablet ibuprofen 400 mg orally, S.O.S. till the morning of the 1st postoperative day was prescribed. Patients were called on 1st, 7th, 20th postoperative days for evaluation.
|Figure 2: (Case 1 homogenous leukoplakia) homogenous leukoplakia of commissures, cryoprobe application, sloughing and healed site|
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|Figure 3: (Case 2 homogenous leukoplakia) homogenous leukoplakia of buccal mucosa, ice ball formation, necrotic area, and healed site|
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Immediate postoperatively, pain assessment was done using wong-baker faces pain rating scale. Topical anesthetic 2% lignocaine was applied in patients who marked “D” (hurts even more) on the pain scale. On 1st postoperative day, slough dimensions, pain, swelling, bleeding, numbness, and trismus were assessed. On 7th postoperative day infection, healing and effect of the procedure on the daily routine of the subjects were assessed. On 20th postoperative day infection, healing and status of the habit after counseling were assessed [Table 3]. A follow-up period of 3 months was done to evaluate any incomplete eradication, recurrence, and scar formation.
|Table 3: Clinical signs and symptoms on 1st, 7th and 20th postoperative days|
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| Results|| |
In this study, out of 25 leukoplakia lesions, homogenous type was most prevalent, i.e., 17 (68%), speckled type were 6 (24%), and verrucous type were 2 (8%) [Table 1].
Immediate postoperatively, majority of the subjects, i.e., 13 (61.90%) marked “B” (hurts little bit), followed by 3 (14.28%) subjects who marked “A” (no hurt). “C” (hurts little more) was marked by 2 (9.52%) subjects and maximum pain rating recorded was “D” (hurts even more) marked by 3 (14.28%) subjects [Table 4]. Two percent lignocaine topical spray was applied immediate postoperatively only in 3 (14.28%) subjects who marked “D” on pain rating scale. In other 18 (85.72%) cases, it was not used.
On 1st postoperative day, 9 (42.85%) subjects marked “A” (no hurt) and 9 (42.85%) subjects marked “B” (hurts little bit), 2 (9.52%) marked “C” (hurts little more), and only 1 (4.76%) marked “D” (hurts even more). Till the morning of the 1st postoperative day, analgesic tablets were used by only 9 (42.85%) subjects with a mean no. of 2.55 tablets. Slough dimensions were adequate (greater or equal to the size of treated lesion) in 25 (100%) treated sites. On the 1st postoperative day, the swelling was present in majority 20 (80%) of the treated sites. None treated sites (0%) had bleeding on either operative day or 1st postoperative day. Only 1 (4.76%) subject had numbness around the treated area on the 1st postoperative day, and none subject (0%) had trismus.
None subjects (0%) had signs of infection on any day and also the status of healing on the 7th postoperative day was assessed based on the analysis of above-mentioned symptoms and all 25 (100%) treated sites had good healing.
In the present study, disturbance in the daily routine of subjects treated with cryosurgery was evaluated on the 7th postoperative day and only 3 (14.28%) subjects were found to be affected due to swelling only.
Twenty-four treated sites (96%) had no signs of infection on the 20th postoperative day. The status of healing on the 20th postoperative day based on the analysis of above-mentioned symptoms showed that 24 (95.28%) treated sites had good healing. One subject did not report back after the 7th postoperative day.
In this study, complete regression was achieved in 22 (88%) lesions, 2 (8%) cases resulted in incomplete regression thus were retreated and complete regression was achieved [Figure 4]. 1 (4%) subject did not report for follow up after 7th postoperative day. 24 (96%) of 25 treated sites showed no scar formation, and 24 (96%) of 25 treated sites showed no recurrence after 3 months.
|Figure 4: Verrucous leukoplakia of buccal mucosa, incomplete regression on the 30th postoperative day, sloughing on 7th postoperative day after retreatment and healed site on the 30th postretreatment day|
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| Discussion|| |
Although freezing techniques have only recently become widespread as a surgical tool, the medical literature has recorded the use of sub-zero temperatures since the time of the earliest records. Probably, the earliest known example in medical literature is the use of low temperature for analgesia by Egyptians documented in “Edwin Smith Surgical Papyrus” written in about 3500 BC and translated into English by Breastead in 1930. James Arnott, an English physician, was the first to report and publish on the therapeutic use of low temperature (−18°C to −24°C) in malignant disease by means of salt/ice mixture applied to breast and uterine neoplasm in 1851.,
The temperatures of −20°C held for 1 min can cause tissue necrosis,, which is instigated by the combined effects of the direct and indirect injury. Direct injury includes: build-up of toxic electrolyte concentrations, pH alteration, protein denaturation, and direct disruption of cell membrane, whereas indirect injury includes vascular effects and immunological response.,,
The studies at ultrastructural level have revealed that the ice crystals are formed within the cells during freezing that leads to disruption of cytoskeleton, but resultant cell damage is due to the osmotic discrepancy rather than mechanical, and the role of microcirculatory failure is secondary in terms of the chronological development of tissue necrosis.,
Cryosurgery has been extensively used in general surgery in the past century, for example, cancerous and noncancerous tissues in liver, lung, kidney, prostrate, brain, skin, breast, bone etc., but from an oral surgery standpoint, cryosurgery begun to be seriously considered in the early 1960s. In maxillofacial surgery, cryosurgery has been used for the management of various pathological conditions such as benign and low-grade bone tumors, application in intra-bony cavities after curettage to prevent recurrence,, in trigeminal neuralgia (cryoneurotomy), in neurogenic pain of temporomandibular joint, and various malignancies of the head and neck. It has been proven to be very promising in this field and particularly the oral mucosa is an ideal site for this technique because of its characteristics of humidity and smoothness.,,
In general, available cryosurgery apparatus is divided into two major categories – The open system and the closed system. In open system direct application of cryogenic liquid is done with cotton swab technique or cryogen is sprayed over the lesion. In closed system, tissues are frozen using a cryoprobe. The closed system cryosurgery offers a greater degree of control but is a more complex and delicate apparatus. Although liquid nitrogen sprays and cotton swabs are more accessible to clinicians are not suitable for use in the oral cavity. Their disadvantage is the lack of control over the temperature achieved within cells and the area of freezing, which makes them hazardous to use intraorally. Furthermore, rapid evaporation of liquid nitrogen from cotton swabs requires numerous applications on the lesion. However, due to the stable contact between cryogen and tissues while using a nitrous oxide cryoprobe, more controlled and profound depth of freezing can be achieved.,
The most interesting feature of cryosurgery in our study was the minimal or no pain intraoperatively and in the postoperative period. Cryosurgery is a painless procedure which was confirmed by many authors, Emmings et al., who treated several patients of oral hemangiomas, hyperkeratosis, and leukoplakia which were painless after treatment. Leopard and Poswillo  also treated various lesion such as hemangioma, lichen planus, hyperkeratosis, and leukoplakia and found same results except in few cases where the mild pain was present postoperatively. Toida et al. treated 18 patients of oral mucous cyst by cryosurgery without any postoperative pain. Marcushamer et al. also treated 6 children with mucoceles on the lower lip using cryosurgery without any postoperative pain. This technique is better tolerated by the fearful young patient. Ishida and Ramos-e-Silva  also treated fibroma, lichen leukoplakia, and mucous cysts by cryosurgery painlessly.
In the present study, most common postoperative complication in patients treated with cryosurgery was mild swelling. It occurs due to the accumulation of exudates in the treated area. Emmings et al., observed that swelling begins soon after complete thawing and reaches its peak in a day and then gradually reduces. Toida et al. treated 18 patients of the oral mucous cyst and noticed slight local swelling after 24 h which remained for 2–4 days. Marcushamer et al. noted mild erythema and swelling, 10 min after the completion of the cryosurgical procedure. On subsequent follow up after 1 week, no swelling was evident. Prasad et al., Yu et al. noticed that hyperemia and edema of the treated area began to appear to immediately after cryotherapy. The swelling increased for 1–2 days and remained for 2–3 days. Narula and Malik  treated 34 patients with various benign oral lesions and observed mild swelling postoperatively.
In the present study, signs of bleeding, trismus, and numbness were assessed on the 1st postoperative day and none of the subjects had any postoperative complication, except for only 1 (4.76%) subject had numbness around the treated area on the 1st postoperative day that resolved by the 3rd postoperative day without any additional treatment. No signs of infection were noticed on 7th and 20th postoperative days in our study which coincide with the findings of studies conducted by Leopard and Poswillo, Prasad et al., Toida et al., Narula and Malik.
In the present study, complete regression was achieved in 22 (88%) lesions [Figure 5]. Two (8%) cases resulted in incomplete regression, 1 (4%) subject did not report for follow up after 7th postoperative day. Two residual lesions (verrucous leukoplakia) were retreated and complete regression was achieved in 4 weeks. Rest all leukoplakia lesions healed normally within 4 weeks ± 4 days. The delayed healing in 1 case of leukoplakia was due to the multiple applications of cryoprobe with increased depth of penetration leading to a larger area of necrosis [Figure 3]. None treated sites showed recurrence or scar formation. Emmings et al., reported the healing time of 4–6 weeks for the lesions treated with cryosurgery. Leopard and Poswillo  noticed that all the oral lesions are usually completely healed with no scar formation in 3 weeks. Toida et al. treated 18 patients of oral mucous cyst by cryosurgery which healed in 2–4 weeks no scar formation. Prasad et al. observed that epithelization was complete within 1–4 weeks, depending on the size and location of the lesion. Yu et al. treated 60 patients with oral leukoplakia using the open method and the healing was complete within 10–14 days for most of the lesions and within 3 weeks in three cases. Narula and Malik  reported the healing time of 2–3 weeks following cryosurgery. Valappila Nidhin et al., treated 10 cases of homogeneous leukoplakia with open spray technique 90% lesions showed normal mucosa with no scar.
|Figure 5: Speckled type leukoplakia of right commissure and homogenous leukoplakia of left commissure and healed site on 30th postoperative day|
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| Conclusions|| |
With the recent development of better equipment, this mode of therapy appears to have a promising role in the management of oral leukoplakia. Thus, its simplicity in application, versatility, low cost, no bleeding, little or no pain, the absence of postoperative infection, scarring and little or no recurrences ascertains that the cryosurgery offer enhanced intraoperative control and better postoperative results for the treatment of oral leukoplakia. The only drawback revealed in this study was the swelling in the early postoperative period and to some extend the appearance of the slough on visible sites.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]