Prof. Paolo Vescovi
DDS, MSc, PhD, Spec. Oral Surgery
Member of Executive Committee of WFLD (World Federation for Laser Dentistry)
Vice Director European Division WFLD
Past-President SILO (Società Italiana di Laser in Odontostomatologia)
Member of the Board of SIPMO (Società Italiana di Patologia e Medicina Orale)
Dir. Master Laser in Odontostomatologia (Prog. EMDOLA : European Master Degree in Oral Laser Applications)

Title: Dental Implants, Bisophosphonates and other antiresorptive drugs and laser.

In June 2014 the Special Committee of the American Association of Oral and Maxillofacial Surgeon (AAOMS) recommended a changing of the nomenclature of Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) in Medication-Related Osteonecrosis of the Jaw (MRONJ). This decision was taken to accommodate the growing number of osteonecrosis associated with other drugs than bisphosphonates (BP), such as antiresorptive (denosumab) and antiangiogenic therapies (tyrosine kinase inhibitors: sunitinib /sorafenib, monoclonal antibodies targeting Vascular Epitheial Growth Factor (VEGF) : bevacizumab).

Dentoalveolar surgery including tooth extractions and dental implants placement is considered the major risk factor for developing medication-related osteonecrosis of the jaw (MRONJ).

A careful evaluation is required when planning dental implant surgery in patients undergoing bisphosphonate therapy because of the risk of developing MRONJ as well as occurring failure of implant. Moreover, complete systemic condition of the patient must be also taking into considering when such procedures are performed.. But not only surgical insertion of dental implants is a potential risk factor for the development of osteonecrosis but also the presence itself of the implant into the bone can be associated with this disease. Therefore, it is necessary to inform of the increased risk for MRONJ also the patients who have already osteointegrated implants and are going to start the BPT. For cancer patients, the implant solution should be avoided due to the high risk of osteonecrosis. The literature instead defines a low risk for patients on bone antiresorptive therapy for osteometabolic diseases. In these patients, prosthetic implant therapy is permitted.

Lasers can be used for surgical and not surgical management of dental implants in cancer and non-cancer patients under antiresorptive /antiangiogenetic drugs and reduce the risk of osteonercosis. The positive effects of different laser wavelengths, both in vivo and in vitro, have been extensively demonstrated and these findings led several authors, in bone diseases, including osteonecrosis of the jaw.

The use of laser photobiomodulation (Nd:YAG, Diode) or Laser surgery (erbium laser), possibly combined with biomaterials or blood-derived growth factors, is indicated during implant placement, perimplantitis management, implants removal. Strict laser assisted periodontal control is indicated for all patients, oncological or non-oncological, who have also received implant-supported prostheses in the past, to prevent the onset of osteonecrosis .

Title: Laser management of early oral cancer (on-line lecture)

The diagnostic pathway for Oral Potentially Malignant Disorders (OPMD) usually starts with the conventional objective examination (COE)  based on inspection and palpation of the oral mucosa with the support of an incandescent light available on the dental chair. It is well known that clinical examination mainly depends on a subjective interpretation, which is a consequence of the experience of the operator. Moreover, oral epithelial dysplasia and early Oral Squamous Cell Carcinoma (OSCC ) may already be present within areas of oral mucosa macroscopically normal, as well as within the context of OPMD such as leukoplakia, erythroplakia, submucous fibrosis and oral lichen planus. A large number of OPMD regardless of its clinical appearance contain a dysplastic component and significant proportion contains carcinomatous foci.  Prompt detection of precancerous and early cancerous lesions could greatly reduce both the mortality and morbidity of oral cancer. OSCC represents the most common malignant tumour in the oral cavity and OPMD are responsible for more than 50 % of oral cancer.   The usual delayed diagnosis and treatment of both, early cancer and pre-cancerous lesions, explains the poor prognostic of OSCC. The development of local recurrence, regional failure, and the formation of second primary tumours induce a 5-year survival rate of about 55%.

The gold standard for the diagnosis of oral dysplastic and neoplastic malignant lesions is the histological examination. Incisional or excisional biopsy techniques are the most reliable methods to collect a surgical specimen suitable for microscopic evaluation. Several adjunctive diagnostic techniques have been proposed in order to increase the sensitivity (SE) and specificity (SP) of conventional oral examination and to improve the diagnostic first level accuracy. Different laser wavelengths offer a prospective new approach in early diagnosis and treatment of OSCC at its various stages either as a stand-alone therapy for early lesions or as an adjuvant therapy for advanced cases. Wavelenghts of 410 – 460 nm are used to examine at risk oral  lesions. Autofluorescence (AF) uses natural fluorophores which are located within the epithelium and the submucosa and which are excited when irradiated with specific wavelengths. Following such irradiation, normal, unaltered mucosa emits a pale green AF light when viewed through a selective, narrow-band filter. Areas of reduced AF (dark areas), but also increased AF (brighten areas), are suspicious for epithelial dysplasia or OSCC. A systematic review of the literature reported that the mean SE and SP for oral displasya detection with AF, were 72.4% and 63.79%, respectively. This technique represents a non-invasive approach designed to visualize early mucosal changes using the principles of tissue AF.  Some premalignant lesions showed clinically indefinite extensions. It is possible that relapses and possible malignant evolution may be associated with incomplete excision of the lesion due to anatomical and morphological features of the oral mucosa in various topographical areas. The AF represents furthermore an important help to evaluate the extent of the lesions beyond their visible margins. It seems of paramount importance to highlight here that benign lesions, or those associated to inflammation, can also be characterized by a loss of stromal AF. The adjunctive application of different wavelengths (Nd:YAG, Er:YAG, Diode, CO2 lasers) in the surgical approach of  early OSCC show many advantages: bleeding reduction, decrease of operative time. Lasers might therefore help improve the postoperative course and reduce the risk of relapses of the disease.