Controlled cryotherapy in the treatment of inflammatory papillary hyperplasia

Controlled cryotherapy in the treatment of inflammatory papillary hyperplasia Lee Getter, Lieutenant Colonel, DC, UXA,” and Bienvenido Lieutenant Colonel, DC, USA**

Perez,

UNITED

REED

STATES ARMY INSTITUTE

ARMY MEDICAL

OF DENTAL

CENTER, WASHINGTON,

RESEARCH,

WALTER

D. C.

Cryosurgery is an effective, painless method for the removal of inflammatory papillary hyperplasia. It requires no local anesthetic, and there is no offensive odor or postoperative or operative bleeding. The method is attended by little postoperative discomfort. Total healing occurs from 3 to 5 weeks postoperatively. The palatal mucosa has a normal appearance and is soft and nontender. A method employing a Freon-cooled probe has been used effectively on twelve patients with inflammatory papillary hyperplasia.

T

he treatment of inflammatory hyperplasia, a benign1 but persistent condition, has been an object of discussion for many years. Many means of treatment have been suggested for it, including surgery,z curettage,l* 2 electrocautery,2s 3 chemotherapy,4 and the use of liquid nitrogen.5 Each of these methods, however, presents some drawbacks.*-3p 5 The purpose of the present investigation was to determine whether some of these objections could be overcome by the use of controlled cryotherapy. METHODS AND MATERIALS The present study is based on the clinical and histologic investigation of inflammatory papillary hyperplasia (IPH) in twelve patients who were treated at the United States Army Institute of Dental Research. The patients represented consecutively referred cases from the Prosthodontic Service. The cryosurgery unit used was a Freon-supplied instrument which was capable of temperatures ranging to -715~ C. (Fig. 1). The apparatus consisted *Chief, Division of Oral Surgery, and Chief, Division of Clinical Research, United States Army Institute of Dental Research. **Assistant Chief, Division of Oral Pathology, and Assistant Chief, Division of Clinical Oral Pathology, United States Army Institute of Dental Research.

178

Controlled

Fig. 1. Freon-operated cryotherapy Fig. 8. Cryotherapy probe.

cryotherapy

179

unit.

of a control unit and a vacuum-insulated tubing which ran from the unit to the freezing tip (Fig. 2). The temperature at the tip was monitored by a thermocouple. In order to determine the temperature in target tissues an additional independent temperature probe was utilized. At first examination the clinical features of the lesion were recorded. A photograph was taken and a portion of the tissue was removed for histologic examination. The cryotherapy probe was applied to an area of the lesion for 45 seconds at -50° to -60° C. This produced a visible formation of ice and whitening of the area (Fig. 3). At the end of 45 seconds the probe was removed and the clinical signs of freezing were allowed to disappear. Then another application, exactly like the first, was made. After two applications to the same site, the target area was changed and another site was subjected to identical treatment. The second area of freezing overlapped the first so as to include a portion of the previously frozen site. No attempt was made at each visit to freeze the entire palatal lesion. The

180

Getter and Perez

Fig. 3. 8, Formation of ice at the area of application of the cryotherapy bleeding area is the site of the preoperative biopsy. Fig. 4. Case 25622. Preoperative clinical view of inflammatory hyperplasia

Oral Surg. August, 1972

probe.

B, The

of the palate.

lesion was divided approximately into thirds, and one third was frozen at each visit. After the treated area had healed, a second specimen of tissue was obtained for biopsy. In the first two patients, heat-sensing probes were placed beneath the area of the freeze in order to determine the limits of the lethal temperature on the bone surface. Their temperature was found not to go below O” C. Since the procedure for inserting the probe required local anesthesia, and since the temperature recorded in the two cases was well above the lethal limit (-21.2O C.),O this procedure was discontinued after the initial two cases. FINDINGS

Patients in these series ranged in age from 32 to 45 years and had an average age of 38 years. All lesions were located on the hard palate and were associated with either partial (50 per cent) or full (50 per cent) dentures. Clinically, the cryotherapy could be administered without local anesthesia of any type. Two of the twelve patients reported a sensation similar to that experienced when “eating a large amount of ice cream.” This occurred during the application of the cryoprobe in the area of the nasopalatine foramen. However, it lasted only for 10 to 15 seconds, and the procedure was completed without resort to local anesthetics. There was no bleeding during or after treatment. After treatment the patients were instructed to wear their dentures as usual. Their prosthetic devices were not lined with dressing of any kind. Postoperatively, patients complained of little or no pain, and those who had discomfort were relieved by non-narcotic analgesics. Detailed descriptions of two selected cases of IPH treated with cryotherapy follow. CASE REPORT CASE 25622

A 40-year-old woman had been referred to the clinic for removal of inflammatory papillary hyperplasia (Fig. 4). She had worn dentures for 10 years prior to her referral to the clinic.

Volume 34 Number 2

Controlled

Fig. 5. Case 25622. Preoperative hyperplasia.

biopsy

specimen

shows marked

cryotherupy

inflammatory

181

papillary

The lesion was biopsied and diagnosed as inflammatory hyperplasia (Fig. 5) of the palate, and cryotherapy was instituted. The lesion was divided into thirds, and the patient was treated in the operatory with the Freon unit. On the fourth to sixth day a necrotic membrane appeared (Fig. 6). At the end of 7 days the tissue sloughed, leaving the healing mucosa in the treated area. Here the treatment was completed in three applications. Complete healing was observed 3 weeks after the last application (Fig. 7). Postoperative biopsy showed a wellhealed palate with no evidence of IPH (Fig. 8). No anesthesia was used during the treatment with the cryoprobe. CASE 25730

A 3%year-old male sergeant had been wearing an upper partial denture for the previous 8 years. The patient was referred for removal of IPH prior to construction of a new partial denture (Fig. 9). The preoperative biopsy revealed formation of small papillary projections covered by an acanthotie, stratified squamous epithelium. The subcutaneous connective tissue showed dense areas of chronic inflammatory cells and increased collagen formation (Fig. 10). The lesion was frozen in two applications, separated by a period of 7 days. At about 2 days after the freeze a necrotic membranous cover appeared (Fig. 11). This sloughed at 7 to 9 days after the operation. The postoperative biopsy showed no evidence of papillary formation, only minimal acanthosis and scattered chronic inflammatory cells (Fig. 12). Healing was completed within 3 to 4 weeks after the operation (Fig. 13).

DISCUSSION Historical

background

Freezing has been used in therapy for many centuries. The first reported use of freezing is in the Edwin Smith Papyrus8 In 1807, after the battle of the Preuss-Eylau, French surgeons used freezing, by packing the patient’s leg in snow, as a means of anesthesia prior to the amputation of the affected limb.g In 1866, freezing by use of ether spray was an effective means of local anesthesia. In 1891, ethyl chloride spray was substituted for ether, and it remains in use to this day.g Freezing in the English language is synonymous with the word anesthesia. It was not until the early nineteen hundreds and the advent of inhalation anesthesia that freezing as an anesthetic agent was slowly discarded.

182

Oral Surg. August, 1972

Getter and Pwez

Fig. 6. Case 25622. Necrotic nxmhnlle 7f’i.q. 7. Cane 2.5622. Postopcrntirc riev

Fig. 8. Case 25622. Biopsy

nppcaring 4 to 6 days after ergotherapy. of healed p:ilntc, 21 days after cryosurgery.

specimen sho~w a well-healed

palate.

In 1845, James Arnott was the first to use local cold in the treatment of cancer. Dr. Temple Fay, in 1936, instituted the use of local applications of cold to palliate patients with inoperable cancer and intractable pain.lO, I1 The advent of sophisticated cryotherapy units in the middle of this century once again brought attention to this modality, and it is now being widely tried in dentistry and medicine.12-22 Cell destruction

in cryosurgery

“The central aim of cryosurgery is to kill all cells in a diseased target area while producing minimal injury to the surrounding healthy tissue.“23 The surgeon must be aware that all tissue in the visibly frozen area will not be killed. The clinical significance of this is that the area of freeze must be extended 2 to 5 mm. beyond the area of the diseased tissue, or the area of freeze must be overlapped in concentric rings so that the periphery of each of the rings is included within the chosen target area.

Volume Number

34 2

Controlled

Fig. 9. Case 25738. Preoperative an existing partial denture.

clinical

view of inflammatory

cryotherapy

papillary

hyperplasia

183

under

The temperature necessary to destroy mammalian tissue is approximately -21.2O centrigrade.6 This temperature represents the eutectic temperature of sodium chloride, which is the main solute in the mammalian tissue. It is at this temperature that the supersaturated sodium chloride freezes. If the temperature change is applied rapidly, intracellular ice crystals form and a more nearly total destruction of the cells occurs. If the temperature is reduced slowly, extracellular ice crystals form, with cell destruction. Cell death with extracellular freezing is not so great as if the freezing occurs within the cells.‘j Maximum lethality is obtained by a rapid freeze and a slow thawing of the tissue.23 If we think of the cryosurgical probe as a heat sink, we realize that only those cells which are in contact with the probe will reach the temperature of the probe. As the distance away from the area of the probe increases, the temperature gradient drops. Cells at the periphery of the frozen area will not be at a temperature necessary for destruction of the cells. These cells are surrounded by a source of heat via the blood supply and will not be destroyed. Therefore, the freeze area in cryosurgery must be extended by increasing the time that the probe is in contact with the tissue, so that the temperature gradient may drop at a point farther from the center of the frozen area. An alternative method is to overlap in concentric rings the area of the freeze so that there is destruction at the periphery of each overlapping circle. In the treatment of benign lesions, bleeding during and after surgery is markedly reduced. In these lesions this is due to rapid thrombosis of the capillary vasculature. Larger arteries and veins in the area resist cryonecrosis.7 It is important to note that in malignant lesions in which the tumor has invaded the walls of large vessels, necrosis of these areas may follow cryosurgery. This may result in postoperative bleeding. Cryotherapy

and

IPH

Under the circumstances of this study the use of cryogenics did not produce any damage to the underlying bone. Since biological materials are relatively poor conductors, it is possible to operate with a relatively secure margin of safety. A good supply of blood to the palate and a rapid rewarming of the periphery enabled us to limit our area of freeze to the involved tissue. In addition to the relative ease of application of the cryosurgery, other factors which make it preferable are: (1) No local anesthesia is necessary.

184

Oral Surg. August, 1972

Getter and Perez

Fig. 10. Case 25’ 738. Preoperative Pla sia of the palab e.

Pig.

biopsy

11. Case 25,738. The appearance

specimen

reveals

of the necrotic

marked

membrane

w rosurg ‘cry. Fig. 11. Case 2;5738. The clinical

appearance

21 days after

cryosurgery

ir

a1t 2

ma1

lyper-

to 4 day‘8 after

Volume Number

34 2

Controlled

Fig. 13. Case 25738. Biopsy

specimen taken at 21 days after

cryotherapy

185

cryosurgery.

(2) There is minimal postoperative discomfort, as compared to that after electrosurgery and curettage. (3) No bleeding is associated with the cryosurgery. (4) The oral mucosa remains intact during and immediately after the operation. (5) There is no contamination of the operating suite or the operator, such as that which occurs in treatment with high-speed rotary instruments. (6) There is no offensive odor during the operation, such as that which is associated with electrosurgery. After cryosurgery, the tissue tends to heal in a soft functional scar. It returns to almost normal, in contrast to the thicker and less flexible scar tissue that tends to form after electrocautery. Further investigations are under way to evaluate various types of cryosurgery probes and their relationship to oral surgery and general practice. Other cooling agents, such as liquid nitrogen and carbon dioxide, are at present under evaluation. SUMMARY Cryosurgery is an effective, painless method for the removal of inflammatory papillary hyperplasia (IPH) . It requires no local anesthetic, and there is no offensive odor or postoperative or operative bleeding. The method is attended by little postoperative discomfort. Total healing occurs anywhere from 3 to 5 weeks postoperatively. The palatal mucosa has a normal appearance and is soft and nontender. The method here described employing a Freon-cooled probe was effectively used on twelve patients with inflammatory papillary hyperplasia. It is suggested that cryotherapy offers promise in the management of IPH and has some advantage over the currently used methods. REFERENCES

1. Bhaskar, 8. N., Beasley, J. D., and Cutright, D. E.: Inflammatory Papillary Hyperplasia of the Oral Mucosa: Report of 341 Cases, J. Am. Dent. Assoc. 81: 949-952, 1969.

186

Getter and Perez

Oral Surg. August, 1972

2. Uobara, G. I., and Federbusch, M. D.: Removal of Papillary Hyperplasia, J. Oral Surg. 26: 463-466. 1968. 3. Thoma, K. ‘H.: Oral Surgery, ed. 4, St. Louis, 1963, The C. V. Mosby Company, pp. 347.14x ---.

4. Schmitz, J. F.: Clinical Study of Inflammatory Papillary Hyperplasia, J. Prosthet. Dent. 14: 1034, 1964. 5. Amaral, W. J., Frost, J. R., Howard, W. R., and Cheatham, J. L.: Cryosurgery in Treatment of Inflammatory Papillary Hyperplasia, ORAL SUFXX 25: 648-654, 1968. 6. Rinfret, A. P.: Cryobiology-Some Fundamentals in Surgical Context. In Rand, R. W. (editor) : Cryosurgery, Springfield, Ill., 1968, Charles C Thomas Publisher, pp. 19-31. 7., Cahan, W. G.: Five Years of Cryosurgical Benign and Malignant Tumors With Hemorrhagic Conditions. In Rand, R. W. (editor) : Cryosurgery, Springfiield, Ill., 1968, Charles C Thomas Publisher, pp. 388-409. 8. The University of Chicago Oriental Institute Publications Vol. III. The Edwin Smith Surgical Papiru?, transl&ed and annotated by James Henry Breasted, Chicago, 1930, University of Clueago Press, vol. 1, pp. 217-224; and pp. 374-391, vol. 2, plate IV. 9. Tytus, J. 5.: Cryosurgery, Its History and Development. In Rand, R. W. (editor) : Cryosurgery, Springfield, Ill., 1968, Charles C Thomas Publisher, pp. 3-15. 10. Smith, L. W., and Fay, T.: Temperature Factors in Cancer and Embryonal Cell Growth, J.A.M.A. 113: 653,. 1939. 11. Fay, T.: Observations on Prolonged Human Refrigeration, N. Y. State J. Med. 40: 1351, 1940. 12. Ostergard, D. R., Townsend, D. E., and Hirose, F. M.: The Long-Term Effects of Cryosurgery of the Uterine Cervix, J. Cryosurg. 2: 52-58, 1969. in the Treatment of Retinal Detachment, J. Cryosurg. 2: 13. Banks, W. S., III: Cryosurgery 30-42, 1969. 14. Barton, R. T.: Cryosurgery in Nose and Throat Tumors, J.A.M.A. 204: 108-111, 1968. A New and Experimental Approach to 15. Odrich, R. B., and Kelman, C. D.: Cryotherapy, the Treatment of Periodontal Disease? J. Periodont. 5: 313-317, 1967. W., Colbns, R. J., and Pappas, H. J.: Historical Aspects of 16. Paloueek, F. P., Batayola, Cryotherapy in Gynecology, J. Cryosurg. 1: 148-159, 1968. 17. Rabkin, R.: Cryogenic Tonsillectomy, Arch. Otolaryngol. 88: 113-116, 1968. 18. Pearson, W: Clinical Experiences With Cryotherapy of the Head and Neck, Laryngoscope 78: 623-631, 1968. Gage, A. A.: Cryotherapy for Oral Cancer, J.A.M.A. 204: 103-107, 1968. ii: Holu, A. : Evaluation of Cryosurgery, Otolaryngology 8: 579, 1970. 21. Emmings, F. G., Koepf, S. W., and Gage, A. A.: Cryotherapy for Benign Lesions of the Oral Cavity, J. Oral Surg. 25: 320-326, 1967. 22. Sippel, H. W., and Emmings, F. G.: Cryotherapy in the Treatment of Recurrent Ossifying Fibroma, Report of Case, J. Oral Surg. 27: 32-35, 1969. Factors Underlying Cell Injury in Cryosurgical Freezing. In 23. Mazur, P. Physical-Chemical Rand, R. W. (editor) : Cryosurgery, Springfield, Ill., 1968, Charles C Thomas Publisher, pp. 32-51. Reprint requests to: Lieutenant Colonel Lee Getter Division of Oral Surgery U. S. Army Institute of Dental Research Walter Reed Army Medical Center Washington, D. C. 20012