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Treatment of amalgam tattoo with an Er,Cr:YSGG laser

Article  in  Journal of Investigative and Clinical Dentistry · August 2010

DOI: 10.1111/j.2041-1626.2010.00011.x

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 Journal of Investigative and Clinical Dentistry (2010), 1, 50–54

CASE REPORT

Treatment of amalgam tattoo with an Er,Cr:YSGG laser

Hasan Guney Yilmaz1, Hakan Bayindir1, Basak Kusakci-Seker1, Simge Tasar2 &
Sevcan Kurtulmus-Yilmaz2
1 Department of Periodontology, Faculty of Dentistry, Near East University, Mersin 10, Turkey
2 Department Prosthodontics, Faculty of Dentistry, Near East University, Mersin 10, Turkey

Keywords
amalgam tattoo, case report,
de-epithelialization, depigmentation, laser.
Correspondence
Assist. Prof. Hasan Guney Yilmaz, Department
of Periodontology, Faculty of Dentistry,
Near East University, Yakin Dogu Bulvari,
Lefkosa, Mersin 10, Turkey.
Tel: +90-533-8328433
Fax: +90-392-6802030
Email: guneyyilmaz@hotmail.com
Received 24 November 2009; accepted
27 March 2010.
doi: 10.1111/j.2041-1626.2010.00011.x
Abstract
Amalgam tattoos are common, asymptomatic, pigmented oral lesions that
clinically exist as isolated, blue, gray, or black macules on the gingival, buccal,
and alveolar mucosae, the palate, and/or the tongue. In this case report, the
successful use of an erbium, chromium-doped:yttrium, scandium, gallium, and
garnet laser for the removal of an amalgam tattoo is explained. A 46-year-old
man is presented with a half decade history of an amalgam tattoo on his left
maxillary premolar–molar gingiva. Depigmentation procedure was performed
under topical anesthesia with the use of an erbium, chromium-doped:yttrium,
scandium, gallium, and garnet laser at 2 W in the soft tissue pulsed mode for
10 min. The pigmented tissue was completely removed. The de-epithelialization
area healed completely on the 10th day after treatment. The period of healing
was uneventful. The amalgam tattoo was completely removed with erbium,
chromium-doped:yttrium, scandium, gallium, and garnet laser, and the treated
area healed without any adverse effect.

traumatized mucosae during the removal of amalgam fill-

Introduction
Amalgam fillings, which are made of a composition of sil-
ver, mercury, copper, zinc, and tin, are commonly used
in dentistry. Amalgam tattoos can be caused by the dis-
placement of metal particles in oral tissues from amalgam
restorations, leaching or corrosion.1 Focal argyrosis or
localized argyria should be avoided, because as well as sil-
ver, mercury and tin are contained in the amalgam alloy.2
The oxidizing ability of the oral cavity corresponds to
the rate of electrochemical reactions, thus it is related to
the corrosion and release of corrosion products. When
dental amalgams and other alloys containing silver are
applied to the restorations of the teeth, they may release
silver in the form of soluble compounds, such as silver
sulfide, and their transportation to the soft tissue and
deposition of silver and other possible metals in the soft
tissue. This explains one of the mechanisms of amalgam
tattoo formation.3,4 Another mechanism can be explained
by iatrogenic or traumatic factors, such as the condensa-
tion of the material in abraded mucosae during routine
restorative amalgam work, entrance of the material within
ings or prosthetic restorations, broken pieces in a socket
or the periosteum during teeth extraction, and interfer-
ence of metal particles in a surgical wound during root
canal treatment with a retrograde amalgam filling.2
Amalgam tattoos frequently appear as asymptomatic,
and colors reported clinically are blue, gray, and black.
They range from 0.1 up to 2 cm in size and can solitary
or multiple. The most commonly-affected sites are the
gingival, buccal, and alveolar mucosae, palate, and ton-
gue.2,5 Once the diagnosis of an amalgam tattoo has been
established according to clinical findings, and the rela-
tionship with present or removed amalgam restorations is
determined, no treatment is necessary, unless the patients’
request aesthetic treatment. Clinicians have explored
techniques to remove lesions. Amalgam tattoos can be
removed by conventional procedures with a scalpel and
diamond burs, surgical excision, and transplantation of
mucosal tissue as epithelialized free soft tissue autograft,6
acellular dermal matrix as an onlay graft,7 connective
tissue graft,8 soft tissue graft–laser treatment combina-
tions,9 and only laser treatment.1

50 ª 2010 Blackwell Publishing Asia Pty Ltd

H.G. Yilmaz et al.
Although erbium, chromium:yttrium, scandium, gal-
lium, garnet (Er,Cr:YSGG) laser is common in dentistry,
to the best of our knowledge, there are no reports that
provide information for the treatment of amalgam tattoo
as a single approach. In this case report, the clinical appli-
cation of Er,Cr:YSGG laser for the treatment of amalgam
tattoos is presented.
Case report
A 46-year-old man was referred to our clinic with a history
of amalgam tattoos on his oral mucosa. An amalgam filling
was made to his maxillary left molar teeth 5 years ago; the
amalgam tattoo occurred approximately 1 year later. His
dentist changed his amalgam fillings and made crowns on
the maxillary premolar and molar teeth according to the
patient’s cosmetic request; however, his dentist referred
him to our clinic because the pigmentation was still present
after the treatment (Figures 1 and 2).
The medical history of the patient was not remarkable,
and there was no history of smoking. Upon clinic exami-
nation, pigmented lesions were observed over the maxil-
lary left premolar–molar, buccal, and palatinal mucosae.
The leaching of metallic particles from amalgam restora-
Figure 1. Presentation of amalgam tattoo on buccal mucosa of max-
illary premolar–molar region.
Figure 2. Presentation of amalgam tattoo on palatinal mucosa of
maxillary premolar–molar region.
ª 2010 Blackwell Publishing Asia Pty Ltd
Treatment of amalgam tattoo with laser
tions, which were made 5 years ago, was found as the
origin of these pigmented lesions by dental anamnesis.
In this case, an Er,Cr:YSGG laser (Waterlase MD;
Biolase Technology, San Clemente, CA, USA) was used.
Topical anesthetic spray (Xylocaine 10% spray; Astra,
Södertalje, Sweden) was applied to the operation field just
before the operation. In compliance with Food and Drug
Administration rules, the patient and staff used special
eyeglasses for protection.
The Er,Cr:YSGG laser application started with soft tis-
sue mode, with a 600-lm sapphire G4 tip (2 W), with a
frequency of 30 Hz, and 30% air/30% water in non-
contact mode by a sweeping motion localized only on the
pigmented areas. The operation was started on the poster-
ior region and continued with the anterior region accord-
ing to the patient’s tolerance to the treatment. The
depigmentation procedure continued until there was no
tattoo remaining. The complete treatment was performed
in 10 min for each region (Figures 3 and 4). There was
Figure 3. Clinical view of buccal mucosa after erbium, chromium-
doped:yttrium, scandium, gallium, and garnet laser depigmentation.
Figure 4. Clinical view of palatinal mucosa after erbium, chromium-
doped:yttrium, scandium, gallium, and garnet laser depigmentation.
51
Treatment of amalgam tattoo with laser
nearly no bleeding on the operation field for the last
depigmentation. Periodontal pack or additional material
was not applied for supporting the healing procedure.
The patient was instructed to avoid alcohol and hot and
spicy foods. An analgesic was not prescribed.
Figure 5. Clinical view of buccal mucosa on postoperative 10-day
follow up.
Figure 6. Clinical view of palatinal mucosa on postoperative 10-day
follow up.
Figure 7. Clinical view of buccal mucosa after 3 months.
52
H.G. Yilmaz et al.
Figure 8. Clinical view of palatinal mucosa after 3 months.
After the procedure, the ablated area was controlled
and examined clinically on the postoperative 10-day fol-
low-up appointment. The ablated wound healed com-
pletely almost after 10 days. The color of the ablated
gingiva was normal and healthy after laser treatment. It
was also similar to the untreated area (Figures 5 and 6).
At 3 months’ follow up, there was no evidence of residual
pigmentation (Figures 7 and 8).
Discussion
Amalgam tattoos are common, pigmented oral lesions
that clinically occur as isolated, blue, gray, or black
patches on the gingival, buccal, and alveolar mucosae.
Before treatment procedures, the amalgam tattoo should
be distinguished from other pigmented mucosal lesions:
nevus, melanotic macules, melanocanthoma, malignant
melanoma, and Kaposi’s sarcoma.5 Biopsy is recom-
mended to confirm diagnosis when there is no radio-
graphic evidence or an adjacent restored tooth.2
Histologically, the amalgam is presented in the tissues
in two forms: as irregular, dark, solid fragments of
metal, or numerous brown and black granules diffused
along collagen bundles and around the blood vessels.
Large-sized fragments are surrounded by dense, fibrous
connective tissue. Smaller-sized particles are combined
with macrophages phagocytosed with small amalgam
particles. The reaction that is described is commonly a
mild, chronic form of a foreign body reaction in which
macrophages and multinucleated giant cells are pres-
ent.10,11 Upon radiographic examination, these lesions
can be diagnosed based on their opaque nature. In this
case, diagnosis was determined as an amalgam tattoo,
according to clinical findings and the relationship with
the removed amalgam restorations. Biopsy was not
required.
Recently, laser ablation has been recognized as an effec-
tive and reliable technique. The present study presents a
ª 2010 Blackwell Publishing Asia Pty Ltd
H.G. Yilmaz et al. Treatment of amalgam tattoo with laser

case of an amalgam tattoo that was completely removed
in a phase procedure with Er,Cr:YSGG laser. Er,Cr:YSGG
laser is a member of the erbium family lasers. The wave-
length of the erbium family lasers lies near the boundary
of the near-infrared and mid-infrared, invisible portion of
the spectrum. The collimated light of this group, with a
wavelength of 2940 nm for the erbium:yttrium–alumi-
num–garnet laser, and 2780 nm for Er,Cr:YSGG laser, are
highly absorbed in water. The water absorption coeffi-
cient of this group is higher than other laser groups
(CO2, neodymium-doped yttrium–aluminum–garnet, diode,
alexandrite, argon). Because of this, the produced laser
light, with wavelengths 2.780 and 2.940 nm, have high
affinity to water in which they are maximally
absorbed.12,13 The epithelium is removed by direct non-
selective ablation due to the water-mediated photo-
thermo-mechanical process which ablates all living cells
within the range of its penetration. Laser energy is
absorbed by water molecules, and it causes quick heating,
vaporization, and micro explosions. These explosions
create high pressure on the surrounding cells that blast
off. Heat escapes by means of vaporization, and ablation
is performed with minimal heating and in the absence of
carbonization.14,15
Intraoperative and postoperative pain reduction and
rapid wound healing are important advantages of the
usage laser over conventional treatment procedures.12
Laser usage has recently been found to reduce pain due
to the protein coagulum that is formed on the wound
surface, acting as a dressing, and the sealing of sensory
nerve ends.16 At the same time, the effect of the low-
power erbium family laser, which scatters or penetrates
into the surrounding tissue, might promote tissue repair.
It is called photobiomodulation, and it works at cellular
levels in toxin reduction, accelerating lymphatic flow, and
increasing blood, thereby supporting the reduction of
pain, enhancing repair, and inducing regeneration by
means of expression collagen and elastic fibers during the
early phase of wound healing.17–19 In addition, the bacte-
ricidal effect of erbium family lasers can generate reactive
oxygen species in irradiated tissue. These oxygen species
have sterilization effects that stimulate fibroblasts, colla-
gen, and extracellular matrix formation.12,18
The first treatment procedure should be connective tis-
sue graft application to protect keratinized tissue volume
against the metal alloy particles, which penetrate deeply
and extensively into the mucosal layers.9 However, in
cases like the one presented, shallow pigmentations can
be easily treated with laser procedure. Laser application
was chosen for depigmentation, although similar results
could be achieved with other options, including blades or
diamond burs. However, the scalpel method is often
complicated by not enough bleeding control and insuffi-
ciency in removing small increments of tissue. It is diffi-
cult to control depth of removal tissue with a diamond
bur, and there is also a risk of imbedding of the metal
particles underneath.1
Despite many advantages of using lasers, there are dis-
advantages that require precautions to be taken during
application. Laser irradiation can interact with tissues,
even in non-contact mode; laser beams can reflect the
eyes of the patient and dentist onto other tissues sur-
rounding the target in the oral cavity. Special protective
eyewear for the laser wavelength must be worn by patient
and staff.20 Dental laser users should attend certification
courses provided by dental organizations, and follow laser
guidelines to understand the characteristics of tissue inter-
action for optimal usage. Finally, the cost and size of laser
devices are still considered too high for their clinical
application.20
Within the limitations of this case report, the treatment
of amalgam tattoos by Er,Cr:YSGG laser procedure is
safe and effective. Postoperative patient satisfaction was
good, aesthetically. The gingiva healed uneventfully. The
Er,Cr:YSGG laser has become a promising laser for peri-
odontal therapy, based on its various characteristics, such
as ablation, vaporization, homeostasis, sterilization effect,
and rapid tissue healing.

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