|Year : 2016 | Volume
| Issue : 2 | Page : 37-42
A clinical and histological comparison of mucosal incisions produced by scalpel, electrocautery, and diode laser: A pilot study
Anuradha Bhatsange, Ekta P Meshram, Alka Waghamare, Lalitha Shiggaon, Vijay Mehetre, Alkesh Shende
Department of Periodontics, ACPM Dental College, Dhule, Maharashtra, India
|Date of Web Publication||29-Dec-2016|
Department of Periodontics, ACPM Dental College, Dhule, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to clinically and histologically compare mucosal incisions of oral tissues after surgical procedures with scalpel, electrocautery, and diode laser. Materials and Methods: Nine standardized incisions were performed in oral mucosa by scalpel, electrocautery, and diode laser. Specimens were classified into three groups according to tool used for surgical excision. Group A: Three specimens excised through a Bard-Parker (BP) scalpel blade no. 15c; Groups B and C included three specimens each excised through electrocautery and diode laser, respectively. Cut margins of biopsy specimens, adjacent peripheral mucosa were evaluated using light microscopy and histologic zones were identified, assessed: For epithelial changes, incision morphology, lateral tissue damage. Intra- and post-operative parameters assessed were the duration of surgery, bleeding, postoperative pain and healing. Results: Immediate hemostasis was seen with electrocautery and laser compared to scalpel (P < 0.011), mean time taken by electrocautery and laser was less compared to scalpel (P < 0.001). The analysis of regularity of incision and postoperative pain experienced by patients revealed a statistically significant difference (P < 0.01). Histologic damage was least with scalpel. The extent of degeneration was lowest with scalpel followed by laser or electrocautery (P < 0.05). Conclusion: Laser and electrocautery have upper hand over scalpel in relation to hemostasis, but have demerits such as lateral heat damage, tissue necrosis, delayed wound healing, and high cost. Even with advanced treatment modality, conventional scalpel treatment is better option in terms of precise incision, lower cost and faster reepithelization than laser and electrosurgery. Heat generating devices may not allow reliable histologic interpretations, particularly assessing margins of small biopsy specimens or malignant conditions.
Keywords: Diode laser, electrocautery, mucosal incisions, scalpel
|How to cite this article:|
Bhatsange A, Meshram EP, Waghamare A, Shiggaon L, Mehetre V, Shende A. A clinical and histological comparison of mucosal incisions produced by scalpel, electrocautery, and diode laser: A pilot study. J Dent Lasers 2016;10:37-42
|How to cite this URL:|
Bhatsange A, Meshram EP, Waghamare A, Shiggaon L, Mehetre V, Shende A. A clinical and histological comparison of mucosal incisions produced by scalpel, electrocautery, and diode laser: A pilot study. J Dent Lasers [serial online] 2016 [cited 2017 Jul 24];10:37-42. Available from: http://www.jdentlasers.org/text.asp?2016/10/2/37/196962
| Introduction|| |
Scalpel, electrocautery, and lasers are being used routinely for oral surgical procedures. Excision of growth, excisional or incisional biopsy, ablation of white lesions, removal of mucocele and gingivectomy are commonly performed intraoral procedures. Each of these devices has their own advantages and disadvantages.
The most widely used cutting instrument in surgery is the scalpel, also known as cold knife and has been considered gold standard cutting tool till now. The scalpel has been used for many years because of its ease of use, accuracy, and minimal damage to adjacent tissue  however scalpel incisions are prone to bleeding that obscures the operative field. Hence, consequently, numerous advanced technologies have been developed to provide hemostasis, comfort to the patient, ease of use and increased visibility. Clinical use of instruments that coagulate vessels as they incise, such as lasers and electrosurgery units, has increased in both medicine and dentistry.
Electrosurgery is a surgical intervention that uses electricity or, more accurately, high-frequency electrical currents to achieve its goal. These high-frequency electrical currents employed in electrosurgery exceed 100 KHz, the most commonly used ones being those that oscillate between 2 and 4 MHz. This type of frequency has the advantage of not producing any of the harmful effects observed with exposure to low-frequency electrical currents. 
The main advantage of the electrocautery is coagulative effect that provides bloodless area and clear view of the operative field. With any device that creates thermal energy to cut or ablate tissue, heat may be dissipated by diffusion into adjacent tissues (conduction), or into the circulating blood (convection). The resulting lateral thermal injury to tissues may result in delayed healing and increased risk of wound dehiscence. 
Medical and dental researchers soon began to study different types of lasers for extra- and intra-oral surgical procedures. Diode laser introduced in mid 90's by Harris and Pick in 1995. More recent reports have also mentioned that diode laser with wavelengths ranging from 810 to 980 nm in a continuous or pulsed mode as a possible instrument for soft tissue surgery in the oral cavity (Suter VG, et al. 2010).  Heat produced during use of laser causes coagulation, protein denaturation, drying, vaporization, and carbonization at the site of the energy absorption. This seals blood vessels and inhibits pain receptors at the incision location. Therefore, using diode lasers might be advantageous because of better control, potentially lower pain and inflammation, and improved wound healing.  Unlike the scalpel, the laser instantly disinfects the surgical wound.
Biopsy is the removal of a tissue sample from a living body with the objective of providing the pathologist with a representative, viable specimen for histopathologic interpretation and diagnosis. The dental clinician should be aware of the various biopsy techniques that are available for the oral tissues, as well as the challenges specific to these tissues. It is classified as (1) excisional biopsy, (2) incisional biopsy, and (3) fine needle aspiration biopsy. Excisional biopsy is the complete removal of a lesion for functional and aesthetic purposes, as well as to confirm the clinical diagnosis. Incisional biopsy provides a representative sample of tissue for diagnostic purposes.  It is the method of choice when the differential diagnosis includes malignancy. In fine-needle aspiration biopsy, sample tissue or fluid is removed through needle without pressure on histological architecture.
It is essential that the whole specimen be clear and readable to make an unequivocal histological diagnosis. Hence, any surgical device that creates thermal or mechanical damage to the tissue to be examined may not be suitable for performing biopsies. Some oral and mucosal lesions need precise incision whereas others need mere excision depending upon the degree of involvement. So far till now these devices were used randomly without giving much attention to the extent of damage done to the adjacent surrounding tissue histologically hence this study was designed to compare and assess the mucosal incisions produced by scalpel, electrocautery, and lasers.
The study was conducted to assess the mucosal incisions produced by scalpel, electrocautery, and lasers.
1. To clinically assess these three cutting tools, i.e., scalpel, electrocautery, and lasers with respect to ease of use, hemostasis, visibility, incisions margins, self-disinfecting nature, healing, postoperative pain and swelling
2. To histologically assess scalpel, electrocautery, and lasers with respect to lateral heat damage, incision margins, and area of degeneration.
| Materials and Methods|| |
This was a randomized controlled clinical trial. Ethical clearance was taken from the Institutional Ethical Committee. Nine patients of age 15 years and above having localized pedunculated swelling were referred to the Department of Periodontics in ACPM Dental College. After clinical examination and diagnosis, the patients had undergone Phase 1 periodontal therapy with oral hygiene instructions. Relevant investigations had been carried out, and they were recalled after 1 week for excision of lesion. Verbal and written informed consent was taken from all patients.
All these nine pedunculated swellings were excised and collected in formalin bottles and sent to Department of Pathology in ACPM Medical College for histopathology. Specimens were subclassified into three groups according to the tool used for the surgical excision.
• Group A, included three specimens excised through a Bard-Parker scalpel blade no. 15c
• Group B included three specimens excised through electrocautery mode with voltage of 1.5 MHz
• Group C included three specimens excised through diode laser with an output power of 1 W in continuous pulse mode.
Postoperatively, analgesics were prescribed as and when required and a chlorhexidine mouthwash for oral rinse twice daily to maintain oral hygiene. Results were obtained, and statistical analysis was carried out.
Evaluation of parameters
Parameters were broadly categorized into intraoperative, postoperative, and histological groups. Evaluation of hemostasis, incision margins, self-disinfecting nature, visibility, heat production, time taken to complete the procedure with each instrument/equipment, postoperative pain and healing was done during and immediately after the procedure. Histologically, incision margins, degeneration, and lateral heat damage was assessed by each of these cutting tools.
Chi-square test was performed for hemostasis, cost-effectiveness, visibility, self-sterilizing property, heat produced by each equipment's, time taken to complete the procedure, for comparing postoperative pain and healing in all groups. Statistical analysis was performed with SPSS software for windows, version 17.0 (SPSS Inc., Chicago, IL, USA). In all the cases, P of < 0.005 was considered statistically significant.
| Results|| |
Nine specimens were collected and subclassified into three groups, i.e., scalpel electrocautery and laser. Results of various intraoperative, postoperative and histological parameters studied were as follows:
Scalpel, electrocautery, and laser were comparable regarding ease of use. Electrocautery and laser were shown immediate hemostasis thus increased visibility during surgical excision procedure. Incisions margins produced by scalpel were well defined than electrocautery and laser groups both clinically and histologically [Figure 1]. During excision, procedure heat was produced by electrocautery and laser so area of charring and lateral heat damage was statistically significant in both groups than scalpel. An area of degeneration was seen more with laser than electrocautery [Figure 2], [Figure 3] and [Table 1].
In the present study, electrocautery was better in hemostasis than scalpel thereby increased visibility and less postoperative pain. Time taken for excision by electrocautery was more which is statistically significant than scalpel. Electrocautery produced heat which ultimately caused delayed wound healing and histologically degenerated areas and lateral heat damage than scalpel [Table 2].
|Table 2: Comparison of two methods (Scalpel and Electrocautery) of cutting soft tissue |
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On comparing scalpel and diode laser, significant differences were found regarding hemostasis, incisions margins, visibility, duration of procedure, heat produced during the procedure, postoperative pain and healing. Histologically, scalpel produced well-defined incisions margins than electrocautery. Furthermore, scalpel does not seem to produce lateral heat damage and area of degeneration [Table 3].
|Table 3: Comparison of two methods (Scalpel and Diode Laser) of cutting soft tissue |
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There was no statistical difference between electrocautery and laser regarding hemostasis, visibility, self-sterilizing property, heat produced by both and incision margins. However, there was statistically significant difference between the times taken by both equipment as laser took more time to cut the tissues than electrocautery. Histologically, charring and lateral heat damage was seen more with laser group than electrocautery [Table 4].
|Table 4: Comparison of two methods (Electrocautery and Diode Laser) of cutting soft tissue |
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| Discussion|| |
Traditionally, the scalpel has been considered the surgical cutting tool of choice because of its precision control, preservation of tissue integrity, and superior association with wound healing. Disadvantages are excessive bleeding, inadequate visibility caused by blood in operating field and nonsterilizing incision cut.
The advantages of laser and electrocautery include coagulation and sealing of small diameter blood vessels and lymphatics resulting in blood free surgical field and minimum postoperative swelling. A reduction in postoperative pain is also achieved as a result of obliteration of sealing of free nerve endings and dendrites. 
Advantages of electrocautery observed are hemostasis is immediate and consistent, tip is self-disinfecting and minimum postoperative pain and swelling and scarring. Disadvantages of electrocautery are dissipation of heat resulting in lateral thermal tissue injury to tissues, delayed healing, unavoidable burning-flesh odor, low tactile sense, and cannot be used near vicinity of bone as it may lead to bone necrosis. 
Various studies have demonstrated the benefits of diode laser in various oral soft tissue procedures. Precise cutting abilities, good coagulation effect and the extremely small zone of thermal necrosis to surrounding tissues are the advantages of using laser. Diode laser are more precise as compared with other systems, including carbon dioxide and neodymium-doped yttrium aluminum garnet lasers. They are optimal for gingival surgery due to their ability to be absorbed by gingival tissue and not by the adjacent structures. The interaction of laser wavelength and energy density with tissues at the tip of fiber optic contact delivery system allows simultaneous cutting and coagulation of tissue.  Disadvantages of laser are expensive armamentarium, produces burning flesh odor, slower than electrocautery and eye damage by laser so protective glasses are required.
The assessment of initial healing after 7 days revealed that healing operated by scalpel was better among all followed by laser than electrocautery.
The histological observations in the present study suggest that scalpel incisions create the least amount of collateral tissue damage and heal more rapidly than the incisions made by diode laser or electrocautery. Delayed healing can be attributed to damage produced by lateral heat. Lateral heat damage is the area of coagulation necrosis produced around the incision line due to unwanted heat production. Decrease in lateral heat production will improve the healing.  Laser and electrocautery produced more degenerative changes in epithelium as compared to scalpel. When carbonization by laser is compared to electrocautery, charring was more apparent in electrocautery group as compared to laser group.
Hall et al. hypothesized that incisions made with lasers vaporize intracellular and extracellular water, forming pressurized steam that ultimately disrupts tissue, with some of the cellular debris becoming charred as it passes through the beam. The degree of carbonization noted in laser specimens in the present study appears to conflict with the observations reported by Filmar et al. who found comparatively more charring in electrosurgery specimens,  but in favor of the study done by Kumar et al. in 2015.
Electrosurgery and laser techniques produce thermal artifacts that may hamper histologic interpretation; accordingly, these methods should be used with caution for diagnostic biopsy or when information from the margins is required. Histologically, laser produced smaller thermal coagulation zone than electrosurgery.  The extent of lateral tissue damage is particularly important for incisions in proximity to bone or, in the case of biopsy of pathologic tissue like malignant conditions or small biopsy specimens; extensive thermal damage may compromise histologic examination and diagnosis. 
A small sample size is also not sufficient to fully understand the pros and cons of any device or to compare superiority or inferiority of one machine over another.
| Conclusion|| |
Both electrocautery and diode laser works well for simple cutting of oral soft tissues. Lasers have more advantages than electrocautery as it can be used in close proximity to bone and better wound healing. Laser and electrocautery produce thermal artifacts that may interfere with histologic interpretation and delayed tissue healing.
Despite these advanced treatment modalities like electrocautery and laser, scalpel has been considered gold standard cutting tool in terms of precise incision, faster healing at much lower cost and seems to be beneficial for excision of small biopsy lesions and malignant conditions.
We acknowledge Dr. Akshay Surana for helping us out in histopathological analysis by electron microscopy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]