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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 128-133

Effect of low-level laser therapy on wound healing after gingivectomy


1 Department of Periodontology and Oral Implantology, B.J.S. Dental College, Hospital and Research Institute, Ludhiana, Punjab, India
2 Department of Conservative Dentistry and Endodontics, B.J.S. Dental College, Hospital and Research Institute, Ludhiana, Punjab, India

Date of Submission24-Nov-2020
Date of Acceptance11-Jan-2021
Date of Web Publication22-Mar-2021

Correspondence Address:
Vikrant Sharma
Department of Periodontology and Oral Implantology, B.J.S. Dental College, Hospital and Research Institute, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_203_20

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  Abstract 


Low-level laser therapy (LLLT) is based on the principle of biostimulation or biomodulation effect. LLLT after gingivectomy has resulted in better wound healing because of its action on collagen synthesis, angiogenesis, and growth factor release. The authors here present a case report on the effect of LLLT, using a diode laser (InGaAsP), on wound healing and patient's response after scalpel gingivectomy.

Keywords: Gingivectomy, low-level laser therapy, wound healing


How to cite this article:
Sharma V, Kalsi D S, Goyal A, Chaudhry S, Oberoi N, Baweja PS. Effect of low-level laser therapy on wound healing after gingivectomy. Indian J Dent Sci 2021;13:128-33

How to cite this URL:
Sharma V, Kalsi D S, Goyal A, Chaudhry S, Oberoi N, Baweja PS. Effect of low-level laser therapy on wound healing after gingivectomy. Indian J Dent Sci [serial online] 2021 [cited 2021 Apr 20];13:128-33. Available from: http://www.ijds.in/text.asp?2021/13/2/128/311684




  Introduction Top


Research and clinical practice using lasers is at its zenith since the past decade. The first prototype of the laser was developed by Maiman in 1960. Today, a wide range of lasers such as diode, CO2, Nd:Yag, and Er:Yag are used in periodontology for hard- and soft-tissue ablation, detoxification of root surfaces, pocket debridement, microbial control, and various surgical approaches.[1] Despite the common use of high-power lasers energy for surgery, there is another lesser-known application of lasers called low-level lasers. Low-level laser therapy (LLLT) was first introduced by Mester et al. in 1967 at Semmelweis Medical University in Budapest, Hungary. In these lasers, a light source generates light of single wavelength, in milliwatt range with wavelengths in the near-infrared spectrum (400–900 nm).[2] LLLT does not cut or ablate the tissues.

The effectivity of LLLT is based on biostimulation or biomodulation effect[3],[4] which states that irradiation of tissues at a specific wavelength can alter cellular behavior.[5],[6] This effect is achieved by action on cellular mitochondrial respiratory chain or on membrane calcium channels and promotes an increase in cell metabolism and proliferation.[7],[8],[9] In vitro and in vivo studies suggest that LLLT improves/increases fibroblast and keratinocyte cell motility collagen synthesis, angiogenesis, and growth factor release leading to increased wound healing.[10],[11],[12],[13]

Various light sources, including helium–neon, ruby, diode, and gallium arsenide, have been used to deliver LLLT under different conditions like treatment of mucositis, paresthesia, and TMJ disorders.[14],[15],[16] In addition, LLLT has also been used for promoting wound healing and reducing pain after gingivectomy, endodontic surgery, orthodontic treatment, and as an adjunct to improve wound healing after nonsurgical periodontal treatment.[17],[18],[19],[20],[21]

We hereby present a case where LLLT was used to improve wound healing after a gingivectomy procedure.


  Case Report Top


A 35-year-old male patient was referred to the department of periodontology with a chief complaint of gingival overgrowth.[Figure 1] Intraoral examination revealed generalized gingival overgrowth involving both maxillary and mandibular anterior teeth. The patient was not taking any antiepileptic, antihypertensive, or immunosuppressive medications that could cause gingival enlargement. His weight and height were considered to be within normal limits and peripheral blood counts were normal which were correlated with an absence of any history of systemic disease. The enlargement was diagnosed as due to periodontitis.
Figure 1: Preoperative picture showing maxillary and mandibular sites to be treated surgically

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The case was assessed and full-mouth SCRP was done. Assessment of need of treatment and extent was done after 3 weeks. It was decided that gingivectomy would be the indicated procedure. After gingivectomy, LLLT was done on buccal gingival of mandibular anteriors and placebo laser aiming light application of the laser unit on maxillary anteriors.

Surgical protocol and low-level laser therapy application

The patient underwent presurgical preparation consisting of full-mouth scaling and root planing with oral hygiene instructions. After 3 weeks, physiologic gingival contours were re-examined for continued need of gingivectomy. It was found that surgical intervention was needed. Gingivectomy was carried out in both the maxillary and mandibular anterior teeth. Excess gingival tissue was excised and gingival was contoured using Kirkland, Orban's knives # 15 Bard-Parker blades, tissue nipper, and scissors. Thereafter, excised tissue was removed using curettes, and gingivoplasty was refined to re-establish suitable gingival contours. After attaining hemostasis, gingival on the buccal surface of mandibular anteriors was irradiated with a diode laser (940 nm), at a power setting of 0.5W applied in a pulse, noncontact mode for 30 s in relation to each tooth. Sham laser application was imitated with aiming light of the laser unit for the control site.

Periodontal dressing (Coe–Pak) was given. This dressing was replaced at 3rd and 7th postoperative visits [Figure 2], [Figure 5] when the laser was reapplied on the mandibular sites, while the maxillary site again underwent laser imitation. On the 14th day, the dressing was removed and the final application of laser was performed. [Figure 8] The pain was assessed on 3rd, 7th, and 14th postoperative visit using a visual analog scale (VAS) score.
Figure 2: Picture showing surgically treated sites on the 3rd day postoperative day after periodontal pack removal

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Figure 5: Picture showing surgically treated sites on the 7th postoperative day after periodontal pack removal

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Figure 8: Picture showing surgically treated sites on the 14th postoperative day after periodontal pack removal

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Maxillary and mandibular wound healing was assessed on 3rd- 7th-, and 14th-day application using a healing index (HI) by Landry et al.[22] which grades the wound healing on a scale of 1–5, where 1 indicates very poor healing and 5 indicates excellent healing. Healing index scoring was given by a different examiner (different from the one who performed the gingivectomy) who did not know which of the two, maxillary or mandibular sites, was actually irradiated by LLLT.

Wound healing was scored after application of LLLT and imitation laser application on each postoperative visit. [Figure 3], [Figure 6], [Figure 9] For this, surgical sites were stained with plaque-disclosing agent (2-tone disclosing agent) to identify the regions of gingiva in which epithelization was incomplete or lacked complete keratinization. [Figure 4], [Figure 7], [Figure 10].
Figure 3: Picture showing application of low-level laser therapy on the mandibular surgical site on the 3rd postoperative day

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Figure 6: Picture showing application of low-level laser therapy on the mandibular surgical site on the 7th postoperative day

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Figure 9: Picture showing application of low-level laser therapy on the mandibular surgical site on the 14th postoperative day

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Figure 4: Picture showing application of plaque disclosing agent to assess healing on 3rd post operative day

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Figure 7: Picture showing application of plaque disclosing agent to assess healing on the 7th postoperative day

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Figure 10: Picture showing application of plaque disclosing agent to assess healing on 14th postoperative day

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The gross surface area was estimated from digital clinical photographs of surgical sites. Darkly stained bluish areas were considered as sites still undergoing active wound healing and having incomplete epithelization. The surface areas of the stained sites in both the test and control sites were compared on 3rd, 7th, and 14th postoperative days.


  Results Top


Healing took place uneventfully in both maxillary and mandibular surgical sites with no complaints of any adverse postoperative complications. On the evaluation of surface keratinization, it was observed that the stained areas of both sites on the 3rd and 7th day were similar. [Figure 4], [Figure 7] However, on the 14th postoperative day, LLLT treated sites, i.e., mandibular sites, showed significantly less surface area that was darkly stained when compared to the maxillary sites demonstrating better surface epithelialization. [Figure 10] Comparison of healing index scores also showed results similar to that of the surface keratinization. Here also, there was no difference in healing scores on 3rd and 7th days. On the 14th postoperative day, a difference in healing was clearly apparent between maxillary and mandibular sites with the LLLT treated site (mandibular sites) having much better look and healing status.

Visual analog scale score



The patient experienced no pain in the mandibular site as compared to the maxillary site where the patient experienced pain after performing gingivectomy procedure.


  Discussion Top


LLLT is a noninvasive, painless process that provides biological therapeutic advantages, including analgesic effects.[23] The use of LLLT for oral and periodontal purposes has been the subject of numerous in vitro and in vivo studies. Increasing interest in the field of LLLT is based on the perceptions of patients who desire minimally invasive and painless treatments.

Numerous studies have been conducted over the years to evaluate healing after periodontal surgical procedures. In this case, the effect of LLLT on wound healing after gingivectomy was evaluated and postoperative pain to check whether LLLT provides any added benefit in improving healing and patient's comfort postsurgically.

The results showed that the pain score in the test site was comparatively less on the 3rd day, 7th day, and 14th days, than on the control site. [Table 1] These results explain the positive effect of LLLT on patient's pain response after gingivectomy. Patients in the test site experienced lower postoperative pain as compared to the control site. Our results are in accordance with a study conducted by Sanz-Moliner et al., who concluded that less pain was reported by patients at the sites where LLLT was performed after modified Widman flap surgery and Tomasi et al. where they concluded that low-level lasers showed analgesic effect when used during periodontal maintenance.[24],[25] However, these results are in contradiction to a study conducted by Masse et al., who did not find a significant analgesic effect of low-level lasers when used after the placement of free gingival grafts.[26] This may due to the heterogeneity of studies, differences in laser parameters used.
Table 1: Showing wound healing and pain scores after 3, 7 and 14 days

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LLLT apart from pain reduction is also known to help in repair process and thus subsequently accelerating the wound-healing process. Low-level laser accelerates the healing process by stimulating mitochondria to increase ATP production to increase reactive oxygen species, which in turn influences redox signaling, affecting intercellular homeostasis of the proliferation of cells.[27] LLLT also has an effect on microcirculation, which reduces edema by changing the capillary hydrostatic pressure.[28] Studies have also suggested that LLLT application may accelerate wound healing by increasing the motility of human keratinocytes and promoting early epithelialization, by increasing fibroblast proliferation and matrix synthesis, and by enhancing neovascularization. It has also been shown that the expression of fibroblast growth factors by macrophages and fibroblasts is increased after LLLT application.

In this case, healing was assessed clinically using Landry et al. HI at all postoperative visits.[22] Healing scores in control as well as test groups increased from day 3 to day 14. [Table 1] Comparison of the mean healing scores within the same group revealed statistically significant differences in both the test and control groups on postoperative day 3, day 7, and day 14. The test group showed visibly better healing as compared to the control group by day 14. [Figure 8], [Figure 10] Our results are in agreement with the study conducted by Amorim et al.[18] and Martu et al. Both the studies reported that the use of LLLT showed better repair and improved healing of the damaged tissues.[18],[29]

In this case, LLLT was applied to the test sites immediately after surgery followed by day 3 and day 7. Diode laser with a wavelength of 940 nm for 30s in the noncontact mode for LLLT and three-time application proved to be sufficient as better wound healing was observed in the test sites. Day 3 and day 7 were selected for LLLT application as there are formation and proliferation of newer blood vessels and fibroblasts in the initial stages of wound healing. This was done in accordance with other studies by Ozcelik et al. and Ahmed who also used LLLT application during the first 7 days of wound healing.[30],[31]

Methylene blue was used to evaluate the wound epithelialization as compared to conventionally used hydrogen peroxide. This was because of the cytotoxic effects of hydrogen peroxide on human gingival fibroblast which could have potentially impaired the wound healing.[32] The results showed that LLLT-applied sites displayed better healing as compared to the control sites. There was less amount of stained surgical area (surface lacking epithelium) in the test sites. These results are in accordance with the study conducted by Ozcelik et al.[30] where they found that the surgical area was less stained in sites treated with LLLT.


  Conclusion Top


Based on the result of this case report, it can be said that LLLT when used as an adjunct to surgical gingivectomy can be used to reduce postoperative pain and discomfort and aid in better wound healing.

Further studies must be conducted to evaluate the effect of adjunctive use of LLLT on wound healing and patients' response.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical clearance

Ethical clearance was obtained from the ethical committee of the institute.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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31.
Ahmed AH. Clinical assessment of low level laser (gaalas) on gingivectomy wound healing. Med J Babylon 2013;10:349-53.  Back to cited text no. 31
    
32.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

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