|Year : 2014 | Volume
| Issue : 3 | Page : 135-139
A comparative evaluation of management of melanin pigmented gingiva using a scalpel and laser
Ambika Bhardwaj, Ashita Sadananda Uppoor, Dilip G Naik
Department of Periodontology, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||18-Dec-2014|
Ashita Sadananda Uppoor
Department of Periodontology, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: There are only a few case reports in the literature evaluating the effects of the diode laser on gingival melanin pigmentation. This study was performed to evaluate the efficacy of melanin depigmentation using a scalpel and diode lasers based on effective removal of gingival pigmentation, recurrence, and patient acceptability. Study Design: Gingival melanin pigmentation at the anterior maxillary or mandibular gingiva at 20 sites from 7 patients was included. Pigmented areas were measured on pre-and post-operative 1 and 6 months using Dummett Oral Pigmentation Index. This was a split mouth study where gingival depigmentation was carried out using a scalpel and diode laser. For one quadrant scalpel techniques were used and for other quadrant laser ablation was done. Results: Ablation of the hyperpigmented gingiva was accomplished with minimal carbonization and almost no bleeding. Postoperative healing was uneventful with no significant postoperative pain. Statistical analysis of the data revealed a significant difference between pre- and post-operative measurements of pigmented area. No significant changes in pigmentation were seen between 1 and 6 months follow-up with both the procedures. Conclusion: Application of diode laser appears to be an effective and safe method for the elimination of gingival melanin pigmentation.
Clinical Relevance To Interdisciplinary Dentistry
- Esthetics plays an important role in treatment planning
Keywords: Depigmentation, diode laser, melanin, physiologic pigmentation
|How to cite this article:|
Bhardwaj A, Uppoor AS, Naik DG. A comparative evaluation of management of melanin pigmented gingiva using a scalpel and laser. J Interdiscip Dentistry 2014;4:135-9
|How to cite this URL:|
Bhardwaj A, Uppoor AS, Naik DG. A comparative evaluation of management of melanin pigmented gingiva using a scalpel and laser. J Interdiscip Dentistry [serial online] 2014 [cited 2019 Jun 16];4:135-9. Available from: http://www.jidonline.com/text.asp?2014/4/3/135/147332
| Introduction|| |
Cosmetic dentistry is a fast growing field that reflects the high esthetic expectations of the dental patient and the current trend in dental science. While cosmetic dentistry is usually centered on esthetic restorative procedures, it also involves the appearance of the gingiva. Dentists may see patients with concern regarding the melanin hyperpigmentation. 
Gingival melanin pigmentation occurs in all races of man. It is well-documented in the literature and is considered to be multifactorial, whether physiological/pathological and can be caused by a variety of local and or systemic factors (Dummett, 1979) including genetic, tobacco use, prolonged administration of certain drugs, especially antimalarial agents and tricyclic antidepressants.  Although clinical melanin pigmentation does not present a medical problem, demand for cosmetic therapy is commonly made by people with moderate gingival melanin pigmentation.
Various depigmentation techniques have been employed with similar results. The various methods include gingivectomy, gingivectomy with free gingival autografting, electrosurgery, cryosurgery, and radiosurgery, chemical agents such as 90% phenol and 95% alcohol, abrasion with diamond bur. One of the earlier and most common techniques for de-pigmentation is the surgical removal of undesirable pigmentation using scalpels, which serve as a gold standard. , The denuded connective tissue heals by secondary intention.
The demand for esthetic dentistry has had a major impact not only on treatment planning, but also on the choice of materials, techniques, and equipment. It is this demand that has married the use of lasers with esthetic dentistry.  The dental laser offers revolutionary advantages over traditional cosmetic dental treatment for our patients. These advantages include precision, hemostasis, sterility, and minimal postoperative pain and swelling. 
Diode laser is found to be efficient for treating a patient's soft tissues as it is absorbed by pigmented (or colored) tissues, specifically melanin, hemoglobin, and oxyhemoglobin. Gingival tissues have a concentration of these; as a result, a diode photon has a high affinity for gingival tissues.  There are only a few reports in the literature evaluating the efficacy of diode laser in gingival depigmentation. This study was performed to compare the efficacy of melanin depigmentation using a scalpel and diode lasers based on effective removal of gingival pigmentation, recurrence, and patient acceptability.
| Materials and methods|| |
In this study, 20 sites from seven patients who visited the Department of Periodontics, with the chief complaint of black gums were included. This was a split mouth study. Gingival depigmentation was carried out from second premolar to second premolar. For one quadrant scraping techniques were used and for other quadrant laser ablation was used. An 810 nm diode laser with power of 0.8 W in continuous mode was used. The criteria for the selection of the patients in the present study were the aesthetic considerations in the periodontally healthy patients. A detailed medical and personal history was recorded. Each patient signed a written informed consent prior to his/her participation in the study.
Detailed extraoral/intraoral examinations, which included the evaluations of the skin pigmentation, the perioral pigmented lesions and the characteristics of the shape, color, surface, and borders of the gingival melanin pigmentation were recorded.
Gingival pigmentation was assessed using Dummett Oral Pigmentation Index (DOPI). Clinical parameters, such as bleeding, redness, swelling, gingival color, recurrence, and difficulty of the procedure, were assessed. Patient response was evaluated in terms of pain and discomfort. The visual analog scale (VAS) was used to evaluate the subjective pain level experienced by each patient.
These clinical observations and patient responses were evaluated according to prepared by Ishii et al. and Kawashima et al. Each parameter was evaluated as A, B, C, or D according to the definition described in [Table 1] and recorded immediately after, and at 1 week, 2 weeks, 4 weeks, 3 and 6 months after the procedure. Patient photographs were taken immediately after procedure, 1 week, 1 month, and 6 months.
A written informed consent was taken before beginning the procedure. Split mouth surgical gingival de-epithelization procedure was performed. Local anesthesia was administered. A split thickness flap was raised and excised, maintaining the normal architecture of the gingiva on the side destined to undergo scalpel de-epithelization. The exposed depigmented surface was covered with Coe-pak periodontal dressing for 1 week. The gingival tissue excised was sent for biopsy.
In the next week, gingival ablation using diode laser was performed on the other side. Topical anesthesia was given to the patient. Remnants of the ablated tissue were removed using sterile gauze damped with saline. The procedure was repeated until the desired depth of tissue removal is achieved. Chlorhexidine 0.2% mouth wash was prescribed. The surgical procedure of gingival depigmentation done using scalpel and diode laser were shown from [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Statistical analysis of DOPI score for scalpel versus laser depigmentation was done using paired t-test. Intragroup comparison at baseline, 1 month and 6 months was done using unpaired t-test. P <0.005 was considered as statistically significant. Statistical analysis was performed using Statistical Program for Social Sciences software version 12 (SPSS Inc., India).
| Results|| |
Mean DOPI at baseline in both scalpel and laser treated sites was 1.77 ± 3.7. Results showed a significant reduction in DOPI with scalpel (P = 0.00) and laser (P = 0.00). No significant changes in pigmentation were seen between 1 and 6 months follow-up with both the procedures [Table 2]. The diode laser used effectively ablated the epithelial tissue exhibiting melanin pigmentation. Immediately after the procedure, gingival connective tissue was exposed. At 1 week, the treated gingiva showed epithelization with a healthy appearance in all cases. At 1 month, gingiva presented no bleeding, redness or inflammation. At the 3 months evaluation, no side-effect was observed in any case. At 6 months, no recurrence was seen.
Bleeding, redness, and swelling were more in scalpel as compared to laser. At the site where scalpel blade depigmentation site was done, bleeding occurred. There was no bleeding at lased depigmentation area.
Patients reported more pain and discomfort in scalpel treated sites as compared to lased sites. Because the patients were under anesthesia, no evaluation of pain or discomfort was made during and immediately after the surgeries. From the VAS evaluation, only 1 patient complained of moderate pain (Score 3.8) 24 h after the procedure. Two patients perceived slight pain, such as irritation or contact pain after treatment.
Complications or side-effects such as gingival recession were not observed in any of the cases. All patients were satisfied with the esthetically significant improvement in gingival color.
| Discussion|| |
Growing demand for esthetics requires removal of excessively pigmented gingival areas, especially in people with high smile lines. Until date, very little literature has been published regarding clinical methods of treatment of pigmented gingiva. The techniques that were tried in the past include chemical cauterization, gingivectomy, scalpel scraping procedure and abrasion of gingiva. The recent techniques of gingival depigmentation in practice are cryotherapy, free gingival autograft and laser therapy and these have achieved satisfactory results.
The use of scalpel technique for depigmentation is most economical compared to other techniques, which require the most advanced armamentarium and is easy to perform and requires minimum time and effort. However, scalpel causes unpleasant bleeding during and after the surgery and it is necessary to cover the surgical site with periodontal dressing for 7-10 days. 
In this study, laser depigmentation provided bloodless field. Initiation of tip provides a hot tip effect, which helps in concentrating energy at the tip. This helps in removing the superficial layer of epithelium without bleeding or trauma to mucosa. Furthermore, the blood vessels surrounding tissue up to a diameter of 0.5 mm were found to be sealed by laser, thus providing hemostasis and a dry field. 
Healing using diode laser was faster as compared with scalpel. The results were in conjunction to a case report by Allen  where complete visual healing was observed at 2 weeks after treatment. The diode laser causes minimal damage to periosteum and bone underlying gingiva being treated and it has the unique property of being able to remove a thin layer of epithelium cleanly. In contrast according to Ozbayrac et al.  healing of laser is slower than scalpel wounds, laser wound is sterile and has no inflammatory reaction.
Postoperative pain following surgery was less with laser as compared to scalpel depigmentation. It is theorized that it may be due to protein coagulum that is formed on the wound surface thereby acting as a biological wound dressing and sealing the ends of sensory nerves. Similar results were seen in the case report by Berk et al. (2005). 
Repigmentation is described as spontaneous and has been attributed to the activity and migration of melanocytic cells from surrounding areas. The present study showed no evidence of repigmentation at 6 months follow-up. The result is in conjunction with other studies (Atsawasuwan et al.).  Tal et al. noticed no gingival repigmentation 20 months after depigmentation by cryosurgery.  Tal et al., using an Er: YAG laser, observed no recurrence after the 6 months follow-up.  In contrast in 1963, Dummett and Bolden  observed partial recurrence of pigmentation in six of eight patients 1-4 months after gingivectomy; Perlmutter and Tal have also reported gingival repigmentation that occurred 7 years after removal of gingival tissues in one patient.  Nakamura et al. described the use of a CO 2 laser in 10 patients who presented repigmentation after 24 months. 
| Conclusion|| |
Compared with the use of a conventional scalpel, lasers can ablate and reshape the oral soft tissue with no or minimal bleeding and little postoperative pain. Thus, Lasers may be a novel, effective tool and a better alternate treatment to more conventional therapies due to its many advantages, including ablation or vaporization, hemostasis, sterilization, and patient compliance. The use this tool effectively can help dentists to make dental treatment more pleasant and acceptable for patients.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]