|Year : 2014 | Volume
| Issue : 1 | Page : 20-25
Comparative evaluation of gingival depigmentation using a surgical blade and a diode laser
Kalakonda Butchibabu, Pradeep Koppolu, Murali Krishna Tupili, Wizarath Hussain, Vijaya Lakshmi Bolla, Krishnanjaneya Reddy Patakota
Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India
|Date of Web Publication||9-Jun-2014|
Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh - 501 101
Source of Support: None, Conflict of Interest: None
Aim: A comparative evaluation of the gingival depigmentation by using a surgical blade and a diode laser; 6 months follow-up. Materials and Methods: Four systemically healthy patients who were aged 21-28 years were selected for the study and were treated with different gingival depigmentation techniques. Diode laser and surgical blade was used for the depigmentation in either of the arches. Pain levels were assessed using a visual analog scale (VAS) during the surgery, 1 day, 3 days and 1 week postoperatively. The recurrence of pigmentation was assessed with melanin pigmentation index (MPI). Results: The gingiva appeared pink and healthy after both the procedures and there was no recurrence of pigmentation. The clinical results obtained with the diode laser were esthetically pleasing with great patient comfort and satisfaction compared to the surgical blade. There was a statistically significant difference between the levels of pain during the procedure and 3 rd postoperative day between the two groups. Conversely there was no difference in the levels of pain 24 hours postoperatively and 1 week postoperatively among the two groups. Conclusion: The laser approach resulted in not as much of bleeding and pain as with scalpel technique. Although no difference in effectiveness and esthetic outcome were found between the two approaches, further well-conducted randomized trials would assist to make the absolute conclusion.
Keywords: Depigmentation, diode laser, hyperpigmentation
|How to cite this article:|
Butchibabu K, Koppolu P, Tupili MK, Hussain W, Bolla VL, Patakota KR. Comparative evaluation of gingival depigmentation using a surgical blade and a diode laser. J Dent Lasers 2014;8:20-5
|How to cite this URL:|
Butchibabu K, Koppolu P, Tupili MK, Hussain W, Bolla VL, Patakota KR. Comparative evaluation of gingival depigmentation using a surgical blade and a diode laser. J Dent Lasers [serial online] 2014 [cited 2017 May 26];8:20-5. Available from: http://www.jdentlasers.org/text.asp?2014/8/1/20/134116
| Introduction|| |
The gingiva is the most commonly pigmented intraoral tissues.  Primary etiologic factor of oral pigmentation is excessive melanin deposition which is seen more in ethnic groups, Caucasians and darker individuals.  Clinically, gingival melanin hyperpigmentation is presented as light to dark brown and occasionally blue black areas that are usually appreciated in the facial aspects of gingiva as diffuse, ribbon-like dark brown bands, or intermittently molded patches with a well-demarcated margin.  Hyperpigmentation can be attributed to both endogenous and exogenous factors. Endogenous factors include medical conditions such as Addison's disease, Peutz-Jeghers syndrome More Details, Von Recklinghausen's disease (neurofibromatosis), etc.  The exogenous factors are heavy metals such as copper, mercury, silver, bismuth, arsenic, lead, and gold or some kind of tattoos like intentional, amalgam, or graphite.  Gingival hyperpigmentation is primarily a cosmetic problem reported by young patients in dental practice. Gingival depigmentation through surgery, chemical, cryosurgery, and electrosurgical means have been used with variable success. ,
With evolving trends, lasers have been used to ablate gingival tissues containing melanin. Different dental lasers have been reported for successful treatment of gingival hyperpigmentation such as carbon dioxide (CO 2 ) laser,  neodymium-doped yttrium aluminum garnet (Nd:YAG) laser,  semiconductor diode laser, and argon laser.  Non-heat producing lasers which are erbirum-doped yttrium aluminum garnet (Er:YAG),  and erbium, chromiumy:T trium, scandium, gallium, garnet (Er, Cr: YSGG)  have also been reported as effective, pleasant, and reliable means with negligible postoperative discomfort and quicker wound healing for depigmentation procedures.
The present case report compares the conventional surgical method using a surgical blade with the use of diode laser for depigmentation in the same patient. The patient's discomfort and satisfaction with both the treatment modalities were analyzed using the visual analog scale (VAS) with a follow-up of 6 months.
| Materials and Methods|| |
Four patients both males and females who were apprehensive with their esthetics were treated with two different depigmentation techniques. The norms for the assortment of the patients were the esthetic concerns in the periodontally healthy individuals. A detailed medical history about systemic diseases and medications which were related with the gingival melanin pigmentation were taken. Patients with acute pulpal or periodontal pain and abscesses were excluded from the study. The patient was prior informed about the possible chances of recurrence after which an informed consent was taken.
After local anesthesia was administered (lignocaine with adrenaline in the ratio of 1:100,000 by weight), [Figure 1] a partial thickness flap was raised with a Bard Parker handle with no. 15 surgical blade where a thin layer of gingival epithelium along with a layer of connective tissue was removed. This procedure was carried out from the first premolar of the right maxillary/mandibular arch to the first premolar of the left maxillary/mandibular arch in all the patients in scalpel group. Hemorrhage during the surgical procedure was controlled by direct pressure applied with sterile saline soaked gauze. Additional care was taken to ensure that all the pigmented areas were removed [Figure 2]. A periodontal dressing was given over the surgical field [Figure 3] and oral hygiene instructions were given to the patients. The patients were advised to use chlorhexidine mouthwash twice daily for 2 weeks postoperatively.
|Figure 1: Preop photograph showing physiologic pigmentation of maxillary and mandibular gingival|
Click here to view
|Figure 2: Immediate post depigmentation of maxillary gingiva with surgical blade|
Click here to view
Postoperatively the patients were given a combination of aceclofenac and paracetamol twice daily for 3 days. Healing was uneventful after 1 week without any unwanted postsurgical complications [Figure 4]. Laser depigmentation was carried out using a diode laser unit (Picasso, AMD Laser Technologies, USA; wavelength 810 nm). Infiltration anesthesia was not required, hence topical anesthetic gel was applied to the surgical field. To comply with the Food and Drug Administration (FDA) laser safety rules, special eye glasses were worn by the patient and the staff. Necessary care was taken to see that there were no shiny or reflective instruments in the operative field which may enhance reflection of the laser beam and might be absorbed by other intraoral regions.
A 400 μm strippable fiber was used with a power setting of 1.5 W in continuous mode for deepithelialization procedure [Figure 5]. With these above said parameters, the laser tip was held close to the gingiva and ablation was performed using paint brush strokes proceeding from the mucogingival junction towards the free gingival margin. After removal of the overlying epithelial tissue, power setting was increased to 2 W to attain rapid ablation for removing the pigments present deep beneath the basement membrane with respect to the interdental papillary areas and minimize the intraoperative hemorrhage from the connective tissue [Figure 6].
|Figure 6: Depigmentation of mandibular anterior gingiva with diode laser|
Click here to view
During the procedure, the surgical field was wiped with sterile gauze soaked in saline every 3-5 min to remove any remnants left out by laser ablation. Thorough examination was done to confirm no pigmented areas were left out [Figure 7]. Periodontal dressing was avoided over the depigmented area. Patient was not given any antibiotic or any analgesic and was discharged from the dental hospital with necessary postoperative instructions. After 3 weeks, the ablated wound healed almost completely [Figure 8] and [Figure 9].
|Figure 7: Immediate post depigmentation of mandibular gingiva with laser|
Click here to view
|Figure 9: Six months postoperative photograph showing esthetically pleasing, pink, and healthy depigmented maxillary and mandibular gingival|
Click here to view
Melanin pigmentation index (MPI; Takashi et al.)  was used to assess the recurrence of repigmentation [Table 1] post-surgery.
|Table 1: Occurrence of repigmentation (melanin pigmentation index score)|
Click here to view
Visual analog scale (Mani et al)
It is used to evaluate the subjective pain level experienced by the patient. VAS consists of a horizontal line of 10 cm long, anchored by two ends, where the left end at "0" denotes no pain and right end at "10" represents unbearable pain, with variable degrees of pain (mild, moderate, and severe) in between. 
In this present case report, the patient was asked to give a scoring from 0 to 10 during the procedure and at 1 st , 3 rd , and 7 th day postoperatively, where VAS score: 0 = no pain; 1-3 = slight pain; 3.1-6 = moderate pain; and 6.1-10 = severe pain
All statistical analysis was done with Statistical Package for Social Sciences (SPSS) analytical software version 15.0. Paired sample test was used to determine the correlations between the two groups.
| Results|| |
The study group comprised both males and females with age range from 21 to 28 years. Demographic data of the subjects is shown in [Table 2]. The gingiva looked raw with noticeable bleeding points immediately after the completion of the treatment, with the scalpel technique. Whereas bleeding points were not noticed with laser depigmentation. Postoperative healing was uneventful in all the patients after 1 week. Comparison of the mean VAS scores concerning to the levels of pain, during and after scalpel and laser depigmentation, is given in [Table 3] and [Figure 10].
|Figure 10: Visual analog scale value assessment between scalpel and laser|
Click here to view
The VAS scores were not prejudiced by the gender or age of the patient in both scalpel and laser groups. Analysis showed statistically significant differences in the patients' pain levels between the two treatment types during the intraoperative period and on the 3 rd postoperative day (P < 0.05). Conversely there was no statistical difference in the levels of pain 24 hours postoperatively and 1 week postoperatively among the two groups (P > 0.05).
| Discussion|| |
'Dark gums' or hyperpigmented gingiva is an esthetic dilemma in many individuals especially if the hyperpigmentation is on the facial or labial aspects of the gingiva and noticeable during smile and speech. It is this esthetic provocation that compels the patient to pay a visit to the dentist. Various treatment modalities including surgery, chemical agents, electrocautery, and cryosurgery have been carried out in the past for correction of pigmented gingiva with variable success. ,
With the advent of new technology in dentistry, lasers have taken over and have been used to ablate the cells containing and producing melanin pigment with appreciable success. Numerous laser systems such as the CO 2 , Nd: YAG, Er: YAG, and diode lasers have been successfully used for gingival depigmentation. ,,,,
In the present study, scalpel surgery was performed for depigmentation in either of the arches in all the patients which resulted in intraoperative bleeding and postoperative discomfort. The scalpel surgery also required profound infiltration anesthesia. A periodontal pack had to be given to cover the depigmented area to minimize patient's discomfort postoperatively.
The diode laser was aptly chosen for depigmentation as the absorption spectrum of the diode laser light (800-980 nm) falls well within the absorption spectrum of the melanin pigment (351-1,064 nm).  The added advantage of the diode laser is minimal depth of tissue penetration causing lesser tissue damage compared to the Nd: YAG laser, which has penetration capabilities of 4-6 mm tissue depth. 
The usage of the diode laser leaves behind a clean and sterile surgical field and due to the good hemostasis primarily resulting from sealed blood vessels of smaller diameter, periodontal pack was avoidable. Postoperative pain from oral surgical procedures has been claimed to be reduced after laser surgery. It is theorized that this may be due to a protein coagulum formed on the wound surface, thereby acting as a biological wound dressing and sealing the ends of sensory nerves. ,
Repigmentation has been observed after depigmentation with various techniques. The mechanism of repigmentation though not clear, according to the migration theory, states that the melanocytes from the adjacent pigmented tissues migrate to treated areas, causing repigmentation.  The severity of repigmentation can be assessed only after a thorough follow-up by the seasoned clinician. Perlmutter and Tal observed partial recurrence after a follow-up of 7-8 years.  In our present study no repigmentation was seen after a 6 month follow-up period in any of the case. However, long-term observations are required to judge the efficacy of a diode laser in the treatment of hyperpigmentation.
| Conclusion|| |
The introduction of lasers has changed the face of dentistry and the same applies to the field of periodontics. With their ease of use, good predictability and minimal postoperative discomfort, lasers have asserted their role in periodontal therapy by leaps and bounds. The advent of lasers has simplified complex procedures and the fact that this technology is driving some conventional and elaborate procedures back into the closet is also noteworthy.
Taking into consideration the excellent clinical outcome, patient satisfaction with ease of technique, the diode laser is a reliable alternative method of depigmentation which not only yields good clinical results but also enhances patient's comfort during and after the depigmentation procedure.
| References|| |
|1.||Tal H, Oegiesser D, Tal M. Gingival depigmentation by erbium: YAG laser: Clinical observations and patient responses. J Periodontol 2003;74:1660-7. |
|2.||Dummett CO, Gaida B. Pigmentation of the oral tissue: A review of the literature. J Periodontol 1967;38:369-77. |
|3.||de Krom JC, van Waas MA, Oosterveld P, Koopmans AS, Garrett NR. The oral pigmentation chart: A clinical adjunct for oral pigmentation in removable prostheses. Int J Prosthodont 2005;18:66-70. |
|4.||Cheraskin E. Diagnosis of pigmentations of the oral tissues. In: Dummett CO, consulting editor. First Symposium on Oral Pigmentation. J Periodontol 1960;31:375-82. |
|5.||Rawal YS, Burrell R, Hamidi SC, Kalmar JR, Tatakis DN. Diffuse pigmentation of maxillary attached gingiva: Four cases of the cultural practice of gingival tattoo. J Periodontol 2007;78:170-6. |
|6.||Perlmutter S, Tal H. Repigmentation of the gingival following surgical injury. J Periodontol 1986;57:48-50. |
|7.||Tal H, Landsberg J, Kozlovsky A. Cryosurgical depigmentation of the gingiva: A case report. J Clin Periodontol 1987;14:614-7. |
|8.||Esen E, Haytac MC, Oz IA, Erdoðan O, Karsli ED. Gingival melanin pigmentation and its treatment with the CO 2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:522-7. |
|9.||Atsawasuwan P, Greethong K, Nimmanon V. Treatment of gingival hyperpigmentation for esthetic purposes by Nd: YAG laser: Report of 4 cases. J Periodontol 2000;71:315-21. |
|10.||Sushma L, Yogesh D, Marawar PP. Management of gingival hyperpigmentation using surgical blade and diode laser therapy: A comparative study. J Oral Laser Appl 2009;9:41-7. |
|11.||Azzeh MM. Treatment of gingival hyperpigmentation by erbium-doped: Yttrium, aluminum, and garnet laser for esthetic purposes. J Periodontol 2007;78:177-84. |
|12.||Berk G. Treatment of gingival pigmentation with Er, Cr: YSGG laser. J Oral Laser Appl 2005;5:249-53. |
|13.||Hanioka T, Tanaka K, Ojima M, Yuuki K. Association of melanin pigmentation in the gingival of children with parents who smoke. Pediatrics 2005;116:e186-90. |
|14.||Mani A, Mani S, Saumil S, Vinayak T. Management of gingival hyperpigmentation using surgical blade, diamond bur and diode laser therapy: A case report. J Oral Laser Appl 2009;9:227-32. |
|15.||Murphy GF, Shepard RS, Paul BS, Menkes A, Anderson RR, Parrish JA. Organelle-specific injury to melanin-containing cells in human skin by pulsed laser irradiation. Lab Invest 1983;49:680-5. |
|16.||Haina D, Landthaler M, Braun-Falco O, Waidelich W. Comparision of the maximum coagulation depth in human skin for different types of medical lasers. Laser Surg Med 1987;7:355-62. |
|17.||Cohen ER, Ammons W. Lasers in periodontics. J Periodontol 1996;67:826-30. |
|18.||Schuller DE. Use of lasers in the oral cavity. Otolaryngol Clin North Am 1990;23:31-42. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]