Use of Laser Therapy in Amalgam Tattoo Removal

Marc Cohn, DDS, Brad J. Wall, DMD, Gregory M. Schuster, DDS, MEd and Rafael Morales, DMD

ABSTRACT (Click here for full study)

Objectives:

To demonstrate a new approach to sequestrectomy using a carbon dioxide (CO₂) laser for a clinic-based technique. Osteoradionecrosis (ORN) of the jaw is a debilitating complication of radiotherapy for head and neck malignancies. Often refractory to medical therapy, surgical intervention for early staged disease with curettage and mechanical bone removal has mixed success, making this disease extremely difficult to treat. Therefore, new approaches to treat ORN of the jaw is needed.

The patient reported a 5-year history of an unsightly dark bluish stain on the palatal tissue between tooth #13 and #14 with no history of trauma or bacterial, viral, or fungal infection other than endodontic treatment of tooth #13. Clinical evaluation confirmed the presence of a lesion sized 4 x 5 mm in length and width near the interdental papillae (Figure 1). Periapical radiographs showed a ceramic/​metal crown on tooth #14 with a large mesial metallic overhang (Figure 1B), the remainder of an amalgam core build-up.

In the absence of other factors, an assumed clinical diagnosis of an amalgam tattoo was established. Due to the lack of clinical changes and its long-standing history, the provider opted not to biopsy the lesion. Removal of the amalgam tattoo with a CO₂ laser was discussed with the patient who consented to such treatment at the next visit.

Methods:

A single visit, surgical ablation of the amalgam tattoo was completed on August 18, 2022, with a 9300 nm CO₂ laser using hard and soft tissue settings of 15.6 W (beam spot size at target of 0.012 cm2, 15% mist, and 60% cutting speed) and a skin contact application technique for about 60 seconds with 20% benzocaine topical anesthetic.

The amalgam tattoo was ablated in a continuous circular motion at 10 to 14 mm above the tissue surface until all the metallic residue and pigmentation were removed (Figures 2A-C). The amalgam overhang was removed during the process and the patient reported no pain during the procedure (Figure 3). Hemostasis was achieved, and no surgical dressing was applied to the site. Irradiance at the target was 1300 W/​cm2, fluence (radiant exposure) was 1.94 J/​cm2, and total radiant energy was 23.3 J.

Results:

The amalgam tattoo was ablated in a continuous circular motion at 10 to 14 mm above the tissue surface until all the metallic residue and pigmentation were removed (Figures 2A-C). The amalgam overhang was removed during the process and the patient reported no pain during the procedure (Figure 3). Hemostasis was achieved, and no surgical dressing was applied to the site. Irradiance at the target was 1300 W/​cm2, fluence (radiant exposure) was 1.94 J/​cm2, and total radiant energy was 23.3 J.

The patient was seen 3 weeks after initial treatment for a post-op visit. The site was healing well with no signs of inflammation and no reports of pain (Figure 4). Several unrelated appointments occurred over the next 8 months with further improvement in the tissue color and on April 13, 2023, a final post-operative visit demonstrated no reported pain, healthy pink tissue with normal contours, and no periodontal pocket depths > 3 mm (Figure 5).

Conclusion:

Amalgam tattoo is encountered by a small percentage of the population and usually does not create a clinical issue once the proper diagnosis has been confirmed. When occurring in the esthetic zone, dentistry can offer a nonsurgical approach to its removal.