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ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 4  |  Page : 251-259

Evaluation of treatment outcome in gingival hyperpigmentation with scalpel Vis-a-Vis Laser: A split-mouth study


Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission28-Sep-2020
Date of Acceptance15-Jan-2021
Date of Web Publication08-Oct-2021

Correspondence Address:
Oliver Jacob
Department of Dental Surgery, INHS Kalyani, Malkapurram, Gandhigram PO, Visakhapatnam - 530 005, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_161_20

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  Abstract 


Context: Melanin pigmentation of the gingiva is a physiological process that occurs in all ethnicities. Many treatment modalities are available to treat gingival hyperpigmentation. These are based on the principle of complete removal of the epithelial layer along with a part of subepithelial connective tissue which is then permitted to heal by secondary intention. Aim: This study aims to compare the treatment outcome of laser and its effectiveness in the management of gingival hyperpigmentation over scalpel. Design: A split-mouth study. Methods: Twenty young patients, between the ages of 18–35 with no systemic comorbidities with concerns regarding of dark-colored gums were selected for the study. A split-mouth study involving treatment of melanin pigmentation using scalpel abrasion on one side (left side upper and lower jaws) and Diode laser (980 nm) on other side (right side upper and lower jaws) was carried out. Observations regarding time taken, amount of bleeding during procedure, postoperative pain, healing of wound, and recurrence were made. Statistical Analysis: Data were analyzed using SPSS version 21.0 for Microsoft Windows. Results: Pain and healing were comparable in both the groups, though intraoperative time consumed and bleeding was significantly lower for laser group. Recurrence also was significantly lower on the laser group. Conclusion: Diode lasers can give better results in the management of gingival pigmentation compared to conventional scalpel abrasion technique.

Keywords: Diode lasers, gingival melanin pigmentation, scalpel abrasion


How to cite this article:
Jacob O, Kosala M, Panwar M. Evaluation of treatment outcome in gingival hyperpigmentation with scalpel Vis-a-Vis Laser: A split-mouth study. Indian J Dent Sci 2021;13:251-9

How to cite this URL:
Jacob O, Kosala M, Panwar M. Evaluation of treatment outcome in gingival hyperpigmentation with scalpel Vis-a-Vis Laser: A split-mouth study. Indian J Dent Sci [serial online] 2021 [cited 2021 Oct 19];13:251-9. Available from: http://www.ijds.in/text.asp?2021/13/4/251/327808




  Introduction Top


Smile of a person seems to have an influence on others and makes a difference in the individual's confidence level. The correction of smile is carried out by cosmetic dentistry which is rapidly progressing and taking over center stage in modern day clinical dental practice. Cosmetic dentistry not only involves the restorative aspect but also the appearance of the gingiva.

Pigmentation is defined as the process of deposition of pigments in the living tissues. Dummett in 1959 classified pigments into six types: Melanin, melanoid, carotene, reduced hemoglobin, oxyhemoglobin, and soft keratin.[1] Pigmentation may appear in the gingiva as early as 3 h after birth.[2] Melanin is produced by melanocytes a type of dendritic cells of neural crest origin which are unattached to the surrounding epithelial cells and behave like unicellular exocrine glands. Physiological melanin pigmentation in the gingiva is caused by melanin deposition by melanocytes located in the epithelium.[3] Many young individuals are conscious of the dark patches the anterior gingiva and these dark patches may have psychological effects on the individuals.[4]

Gingival depigmentation procedure as a part of periodontal plastic surgical procedures is the treatment modality to remove the melanin hyperpigmentation. Scalpel surgery has been traditionally used to treat hyper-pigmented gingiva. Scalpel technique is considered “Gold Standard” for the management of gingival pigmentation.[5] Other techniques include chemical agents, free gingival autografts, acellular dermal matrix allografts, electrosurgery, cryosurgery, radiosurgery, abrasion with diamond burs, and various types of lasers. Among the various lasers, diode laser is the most commonly used. They function on the principle of absorption of photons by pigments such as melanin and ablation of these cells. The aim of this study was to compare Diode lasers with scalpel abrasion method for depigmentation of gingiva.


  Methods Top


Patient selection

This analytical single surgeon split-mouth study was conducted from mixed Indian population of patients from November 1, 2017, to June 30, 2019. Patients with complaint of black gums between the ages of 18-35 years of age [Figure 1] and with good oral hygiene were included for the study. Pregnant and lactating women, individuals with systemic comorbidities and on medications and patients with poor oral hygiene were also excluded from the study. The study groups were divided into two groups: Group A: Right half: upper and lower central incisors to premolars will be treated using diode laser [Figure 2] Group B: Left half: upper and lower central incisors to premolars will be treated by Scalpel technique. Baseline assessment was taken for all patients using Dummett Oral Pigmentation Index (DOPI) given by Dummet CO[6] for intensity of pigmentation and Hedin Pigmentation Index (HPI) given by Hedin[7] for the extent of pigmentation [Figure 3]. Informed consent was obtained prior to commencement of the study. The study was approved by the Local Ethical committee. All the procedural steps were carried out by a single operator.
Figure 1: Preoperative clinical presentation with pigmentation

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Figure 2: Diode laser equipment with armamentarium

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Figure 3: Hedin Pigmentation Index

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Gingival epithelium from the mucogingival junction to the marginal gingiva including the interdental papilla was denuded by diode laser in contact mode using horizontal brush strokes on the side assigned to laser ablation (Group A) [Figure 4]. Four weeks later, depigmentation of the contra lateral side was carried out using surgical abrasion method for the side assigned to surgical scalpel technique (Group B) [Figure 5]. Periodontal pack was placed at the site after each procedure for 7 days. Oral hygiene instructions were advised to all the patients post treatment. Restriction on consumption of hot and spicy foods for 1 week was advised and analgesics were prescribed. Chlorhexidine mouth wash (0.2%) was used for chemical plaque control for 2 weeks' postsurgery.
Figure 4: Depigmentation by diode laser ablation on right side Group A

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Figure 5: Depigmentation by scalpel abrasion on left side Group B

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Intraoperative evaluation of time consumed for the procedure and bleeding during the procedure was measured using the bleeding index given by Ishi and Kawashima.[8] Postoperative evaluation was carried out to check for patient discomfort and pain using the visual analogue scale (VAS)[9] after 4 h, 24 h, 07 days, 12 days, and 21 days. Wound healing was assessed using Peroxide test describes by Avenghi[10] with 3% H2O2 [Figure 6] to check the integrity of the epithelial barrier after 7 days, 12 days, 21 days, and 28 days. A value of 1 was allotted to positive test, i.e., presence of effervescence and 0 to negative result, i.e., the absence of effervescence. The recurrence of pigmentation was assessed after 3 months, 6 months, and 9 months [Figure 7],[Figure 8],[Figure 9]. The re-evaluation of the re-pigmentation was assessed using the DOPI and HPI.
Figure 6: Peroxide test to detect epithelial regeneration

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Figure 7: Postoperative comparison of both groups at 3 months

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Figure 8: Postoperative comparison of both groups at 6 months

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Figure 9: Postoperative comparison of both groups at 9 months

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Statistical analysis

The sample data of the study was statistically analyzed using Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp) for MS Windows. The data on categorical variables shown as n (% of cases) and the data on normally distributed continuous variables were presented as the mean and standard deviation across the two study groups. For non-normally distributed continuous variables, median (min – max) was used. The inter-group statistical comparison of distribution of categorical variables was tested with Chi-square test or Fisher's exact probability test. The inter-group statistical comparison of normally distributed continuous variables was done with independent sample t-test and non-normally distributed continuous variables were done using Mann–Whitney U-test. The intra-group statistical comparison of medians of non-normally distributed continuous variables and distribution of categorical variables was done using Wilcoxon signed-rank test. The underlying normality assumption was tested before subjecting the study variables to t-test. The P < 0.05 was considered to be statistically significant.


  Results Top


A total of 20 patients were studied. The distribution of male: female ratio was 3:2. The study being a split-mouth design had even distribution of males and females in both test and control groups [Graph 1]. The mean of age of cases studied in Group A and Group B was 26.00 ± 6.28 years [Graph 2].



Baseline pigmentation assessment

All patients selected for the study had a DOPI score of more than 2. The study design being a split mouth study both the groups had similar baseline DOPI scores [Graph 3]. Among the 20 patients selected for the study who met the inclusion criteria, 7 (35.0%) had HPI score 3 and 13 (65.0%) had HPI score 4 [Graph 4].



Intraoperative evaluation of time consumed for procedure showed Group B consumed more time (29–36 min with a median of 33 min) in comparison to Group A (15–22 min with a median of 16 min). The distribution of median operating time was significantly higher in Group B compared to Group A (P < 0.001) [Table 1]. Bleeding index of Group A lesser than Group B which was statistically significant (P < 0.001) [Table 2].
Table 1: Inter-group distribution of average operating time among the cases studied

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Table 2: Inter-group distribution of bleeding index among the cases studied

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Postoperative evaluation

The average pain score on the VAS after 4 h for Group A and Group B was 4 and by 24 h it reduced to 2 in both the groups. Intra group analysis showed a significant difference (P = 0.001) [Table 3]. The median pain score (VAS) at 4-h, 24-h, 7-days, 12-days, and 21-days did not differ significantly between the two groups (P > 0.05 for all) [Table 3] and [Graph 5]. Intra-group analysis of median wound healing score showed in Group A had significantly higher score at 7 days (P < 0.001 for all). In Group B, the distribution of wound healing score at 7 days did not differ significantly compared to median wound healing (P > 0.05 for all) [Table 4]. The median wound healing score at 7 days, 12 days, 21 days, and 28 days did not differ significantly between two study groups (P > 0.05 for all) [Table 4].
Table 3: Inter-group and intra-group distribution of average pain score (visual analog scale) among the cases studied

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Table 4: Inter-group and intra-group distribution of average wound healing score among the cases studied

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The assessment of recurrence rate intragroup DOPI score at baseline was significantly higher compared to DOPI scores at 3 months, 6 months, and 9 months (P < 0.05 for all) for Group A and Group B [Table 5] and [Graph 6]. Inter-group analysis showed that the DOPI score of 1 at 3 months was 25% for Group A and score of 1 and 2 in 20% and 25%, respectively for Group B. The inter-group analysis at 6 months showed 55% of Group A had DOPI score of 1, whereas 50% of the cases in Group B showed DOPI score of 2. At 9 months, 70% of cases of Group A showed DOPI score of 1, whereas 60% of the cases of Group B showed DOPI score of 3. The analyses showed that the recurrence in Group A was lesser compared to Group B at 3 months, 6 months, and 9 months and was statistically significant (P < 0.05 for all) [Table 5] and [Graph 7].
Table 5: Inter-group and Intra-group distribution of repigmentation (Dummet Oral Pigmentation Index) among the cases studied

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Intra-group analysis of HPI at baseline was significantly higher compared to HPI scores at 3 months, 6 months, and 9 months (P < 0.05 for all) [Table 6] and [Graph 8]. Inter-group analysis showed that the HPI score of 1 at 3 months was 25% for Group A and 45% for Group B. At 6 months marked difference between the groups was seen with 50% of the cases of Group A showed HPI score of 1 and 35% of the cases in Group B showed HPI score of 2. At 9 months, 65% of cases of Group A showed HPI score of 1, whereas 45% and 30% of the cases of Group B showed HPI score of 2 and 3, respectively. The analysis showed that the extent of recurrence in Group A was lesser and the distribution of extent of repigmentation with HPI score at 3 months, 6 months, and 9 months was statistically significant (P < 0.05 for all) [Table 6] and [Graph 9].
Table 6: Inter-group and Intra-group distribution of repigmentation (Hedin Pigmentation Index) among the cases studied

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  Discussion Top


Several modalities exist for the treatment of pigmentation such as free gingival autografts, cryosurgery, electro-surgery, scalpel abrasion, and split thickness slicing, lasers and chemical such as 90% phenol. However, these methods have their own disadvantages. Depigmentation procedure is commonly undertaken by de-epithelization of the gingiva by surgical abrasion. During this process, the epithelium is completely scraped off with a part of the subepithelial connective tissue. Subsequently, epithelium generally regenerates by the 7th day and forms the normal barrier.[10]

Scalpel abrasion surgery has been traditionally used to treat hyperpigmented gingiva. They function on the principle of complete removal of epithelial layer along with a part of subepithelial connective tissue which is then permitted to heal by secondary intention. The new epithelium that forms is devoid of any melanin pigments.[11]

Diode is an excellent soft-tissue laser and it is indicated for cutting and coagulating gingival tissue. The use of semiconductor diode laser for depigmentation procedure was introduced by Yousuf et al. in 2000.[12] The semiconductor diode laser is made up of aluminum, gallium and arsenide diode emitting radiation in continuous mode and operated in a contact method using a flexible fiber-optic delivery system. Laser light at 980 nm is poorly absorbed by water, but highly absorbed in hemoglobin and other pigments. Since, the diode laser basically does not interact with dental hard tissues, is an excellent soft tissue surgical laser indicated for cutting and coagulating gingiva and oral mucosa.[13],[14] Laser treatment is used to remove melanin pigment by ablating epithelial tissues up to the suprabasal and basal layers of the epithelium, where melanocytes reside. Laser requires melanocytes to lie within its range of penetration and to contain melanin in order to absorb laser wavelength energy by the pigments, causing photothermolysis of the melanocytes in the epithelial layers.

Scalpel technique is simple to learn and easily carried out in different clinical setups. Scalpel technique is considered simple due to the less equipment constraint. However, immediate post-operative pain and discomfort are greater in scalpel technique and leaves a raw bleeding wound which needs to be covered using a periodontal dressing.[15] It is a fact which was confirmed by the results of this study which showed excessive bleeding and discomfort to the operator during procedure. The additional effort to control the bleeding areas sequentially led to the increase in time consumed for the procedure in each patient. This indicates that the amount of bleeding that could lead to operator inconvenience was less in the laser group as compared to the scalpel groups. It also provides a clean dry field by providing hemostasis reducing the operators discomfort and reduced time taken to complete the procedure. It was evidently shown during the study.[16]

Pain and discomfort experienced by the patients analyzed on VAS is a subjective assessment. This scale is charted on a scale of 100 mm.[9] Studies have shown that pain and discomfort was comparatively lesser with use of lasers as compared to scalpel.[17] This study showed a slightly higher discomfort on the laser side as compared to the scalpel groups. This could be attributed to the thermal effect of the laser on the adjacent tissues. This was in conformity with split-mouth depigmentation study by Kumara et al.[18] Although healing of laser wound is slower than healing of scalpel wounds, a sterile inflammatory reaction occurs after lasing. Complete epithelialization blocks the activity of subepithelial connective tissue enzyme catalase that degrades hydrogen peroxide (H2O2) to water (H2O) and oxygen (O) showing effervescence when applied over open wounds. This test proves the completion of epithelial barrier as described by Avenghi et al. in his study in 1998.[10] Lasers due to their ablative nature on the cells have shown slower wound healing as compared to scalpel technique[16] and this was confirmed by this study.

Oral repigmentation refers to clinical reappearance of melanin pigment after a period of clinical depigmentation of the oral mucosa. The decreased intensity of pigmentation may be due to less production of melanin pigments. Recurrence of pigmentation has been attributed to the migration of melanocytes from the adjacent untreated sites or from the remnants of the melanocytes left behind at the surgical site. These remnant melanocytes may become activated and start synthesizing.[19] Recurrence was effectively reduced in the laser group due to ablation of the melanocytes which reduced their number as compared to scalpel technique, where there was no ablation of melanocytes seen. This reduced recurrence rate in our study concurs with the randomized split-mouth study conducted in 2017 by Mahajan and Kaur.[20]


  Conclusion Top


Within the limitations of a small sample size, the study has proven that diode laser is superior. It is suggested a similar study with larger sample size along with histochemical and histological assessment for the melanocytic activity is warranted to establish a clear cut evidence in favor of diode laser technique for depigmentation.

Ethical clearance

Ethical Committee, AFMC: IEC/Oct/2017 dated 16 Oct 2017.

Acknowledgments

Brig (Dr) S K Bhandari, Head of Department of Dental Surgery and Oral Health Sciences, AFMC, Pune and Col (Dr) V B Mandlik (Retd), Professor of Periodontology, Department of Dental Surgery and Oral Health Sciences, AFMC, Pune for their support and guidance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dummett CO. Oral pigmentation-physiologic and pathologic. N Y State Dent J 1959;25:407-12.  Back to cited text no. 1
    
2.
Hermann P. Pigmentation of the oral mucous membrane. Dent Cosm 1932;72:554-61.  Back to cited text no. 2
    
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Dummett CO. Overview of normal oral pigmentations. J Indiana Dent Assoc 1980;59:13.  Back to cited text no. 3
    
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Dummett CO. Mental attitudes towards oral pigmentations. Mil Med 1969:134:119-23.  Back to cited text no. 4
    
5.
Hegde R, Padhye A, Sumanth S, Jain AS, Thukral N. Comparison of surgical stripping; erbium-doped: yttrium, aluminum, and garnet laser; and carbon dioxide laser techniques for gingival depigmentation: A clinical and histologic study. J Periodontol 2013;84:738-48.  Back to cited text no. 5
    
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Dummett CO, Gupta OP. Estimating the epidemiology of oral pigmentation. J Natl Med Assoc 1964;56:419-20.  Back to cited text no. 6
    
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Hedin CA. Smokers' melanosis. Occurrence and localization in the attached gingiva. Arch Dermatol 1977;113:1533-8.  Back to cited text no. 7
    
8.
Ishii S, Aoki A, Kawashima Y, Wantanabe H, Ishikawa I. Application of an Er: YAG laser to remove gingival melanin hyperpigmentation: Treatment procedure and clinical evaluation. J Jpn Soc Laser Dent 2002;13:89-96.  Back to cited text no. 8
    
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Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: Clinical significance in postoperative patients. Anesthesiology 2001;95:1356-61.  Back to cited text no. 9
    
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Avagehi ME. Mucosal wound healing is impaired by examination stress subject characteristics and timing of wounds whole blood assay for IL-1 β. Psychosom Med 1998;60:362-5.  Back to cited text no. 10
    
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Pal TK, Kapoor KK, Parel CC, Mukharjee K. Gingival melanin pigmentation: A study on its removal for esthetics. J Indian Soc Periodontol 1994;3:52-4.  Back to cited text no. 11
    
12.
Yousuf A, Hossain M, Nakamura Y, Yamada Y, Kinoshita J, Matsumoto K. Removal of gingival melanin pigmentation with the semiconductor diode laser: A case report. J Clin Laser Med Surg 2000;18:263-6.  Back to cited text no. 12
    
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Cobb CM. Lasers in periodontics: A review of the literature. J Periodontol 2006;77:545-64.  Back to cited text no. 13
    
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Suragimath G, Lohana MH, Varma S. A split mouth randomized clinical comparative study to evaluate the efficacy of gingival depigmentation procedure using conventional scalpel technique or diode laser. J Lasers Med Sci 2016;7:227-32.  Back to cited text no. 14
    
15.
Bakutra G, Shankarapillai R, Mathur L, Manohar B. Comparative evaluation of diode laser ablation and surgical stripping technique for gingival depigmentation: A clinical and immunohistochemical study. Int J Health Sci (Qassim) 2017;11:51-8.  Back to cited text no. 15
    
16.
Akira A, Koji M, Frank S, Anton S, Yukna RA, Takasaki AA, et al. Periodontal and peri-implant wound healing following laser therapy. Periodontol 2000 2015;68:217-69.  Back to cited text no. 16
    
17.
Doshi Y, Khandge N, Byakod G, Patil P. Management of gingival pigmentation with diode laser : Is it a predictive tool ? Int J Laser Dent 2012;2:29-32.  Back to cited text no. 17
    
18.
Kumara Ajeya EG, Avinash JL, Rajiv NP, Galgali Sushama R. Split mouth gingival depigmentation using blade and diode laser – A case report. Ann Dent Res 2011;1:91-5.  Back to cited text no. 18
    
19.
Sameer AM. Management of gingival hyperpigmentation by surgical abrasion: Report of three cases. Saudi Dent J 2006;18:162-6.  Back to cited text no. 19
    
20.
Mahajan G, Kaur H, Jain S, Kaur N, Sehgal NK, Gautam A. To compare the gingival melanin repigmentation after diode laser application and surgical removal. J Indian Soc Periodontol 2017;21:112-8.  Back to cited text no. 20
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