SCALPEL VERSUS DIODE LASER FOR GINGIVAL DEPIGMENTATION: A CASE REPORT

Gingival hyperpigmentation is believed to be a genetic trait in populations and is more appropriately termed physiologic or racial gingival pigmentation; a condition, which affects all races differently. Gingival depigmentation is most frequently performed as an esthetic periodontal plastic surgical procedure. There are various procedures like scalpel, laser. Cryosurgery, diamond burs and chemical methods have been used in this procedure. This case report compares the efficacy of two techniques. Maxillary anterior region was treated with scalpel technique and the mandibular anterior region was treated using Diode Laser. Both the treatment modalities were effective in terms of patient acceptance. Scalpel depigmentation resulted in uneventful healing of the treated site. Laser depigmentation showed some beneficial effects like bloodless field during surgical procedure which healed uneventfully. Patient discomfort was more in laser treated site during the initial healing period as compared to scalpel.

Gingival hyperpigmentation is believed to be a genetic trait in populations and is more appropriately termed physiologic or racial gingival pigmentation; a condition, which affects all races differently. Gingival depigmentation is most frequently performed as an esthetic periodontal plastic surgical procedure. There are various procedures like scalpel, laser. Cryosurgery, diamond burs and chemical methods have been used in this procedure. This case report compares the efficacy of two techniques. Maxillary anterior region was treated with scalpel technique and the mandibular anterior region was treated using Diode Laser. Both the treatment modalities were effective in terms of patient acceptance. Scalpel depigmentation resulted in uneventful healing of the treated site. Laser depigmentation showed some beneficial effects like bloodless field during surgical procedure which healed uneventfully. Patient discomfort was more in laser treated site during the initial healing period as compared to scalpel. Copy Right, IJAR, 2021,. All rights reserved.

…………………………………………………………………………………………………….... Introduction:-
Smile is a manifestation of self-confidence involving aesthetic and psychological factors that include teeth, lips, and gingival tissue. 1 The harmony of smile is determined by the shape, position and color of the teeth, and also by the gingival tissues. Melanin pigmentation of the gingiva occurs in different amount in different races. Melanin, a brown pigment, is the most common cause of endogenous pigmentation of gingiva. In some population, Gingival hyperpigmentation is seen as a genetic trait and is more appropriately termed as racial or physiologic gingival pigmentation. 2 Oral melanin pigmentation may have multifaceted etiologies including genetic factors, tobacco use, systemic disorders and prolonged administration of certain drugs especially antimalarial agents and tricyclic antidepressants. 3 Melanin hyperpigmentation is not present as a dental problem, but reveal unesthetic appearance. This is commonly seen in patients with excessive gingival display while smiling. 4 The normal color of healthy gingiva is coral pink. However, wide variations are observed. The factors affecting gingival color include vascularity, thickness, keratinization and gingival pigmentation. 5 Gingival depigmentation is a periodontal plastic surgical procedure whereby the gingival hyperpigmentation is removed or reduced by various techniques. 6 Here is a case-report of gingival hyperpigmentation in which two different techniques were used in different quadrants to treat the condition and to compare the clinical efficacy of scalpel and laser.

Methods of
Case Report:

Materials and Method:-
A 19 year old female patient visited to the department of Periodontology & Implantology, Subharti Dental College & Hospital, Swami Vivekanand Subharti University, Meerut with the chief complaint of black gums (Fig-1). Patient was systemically healthy with good oral hygiene. Considering the patient's esthetic concern she was explained about the various treatment options available and the possibility of repigmentation after certain period of time. A split mouth approach comparing scalpel technique with diode laser was carried out. Local infiltration of lignocaine was administered. Exposure parameters are set using the recommended guidelines, followed by careful removal of epithelium containing melanin layer. There was absolutely no bleeding during the procedure.

Procedure
After explaining the whole procedure to the patient a written informed consent was signed by the patient. A detailed medical history, along with blood investigations were carried out to rule out any contraindication for surgery.
Conventional technique of scalpel was planned for upper anterior region using a #15 blade, followed by periodontal dressing over the surgical area. Laser for mandibular anterior region was planned.

Conventional Technique
After local infiltration of 2% lignocaine, conventional technique of scalpel was planned for upper anterior region using a #15 blade (Fig-2). Pigmented tissue was excised, maintaining the normal architecture of the gingiva (Fig-3).
Bleeding was controlled using pressure pack with sterile gauze. The exposed depigmented surface was covered with CoePak periodontal dressing for 1 week (Fig-4). Analgesic was prescribed for the management of pain. After 1 week, the pack was removed and the surgical area was examined. On 1 month postoperative follow-up, the areas were completely healed (Fig-5).

Laser Technique
Depigmentation in mandibular anterior teeth was done using a diode laser of 980 nm wavelength (Sunny Gold) ® (Fig-6). The laser was used in continuous mode at a power output of 2 W. Melanin pigmented gingiva was ablated with a flexible, hollow-fiber delivery system in the contact mode under standard protective measures. Laser has the advantages of easy handling, short treatment time, hemostasis, and decontamination and sterilization effects. After local anesthesia, the procedure was performed on all pigmented areas. Remnants of the ablated tissue were removed using sterile gauze damped with saline. This procedure was repeated until the desired depth of the tissue (Fig-7). After total ablation of the pigmented mucosa, the exposed depigmented surface was covered with CoePak periodontal dressing for 1 week (Fig-8). The patient returned after 30 days presenting healthy gingiva and the absence of melanin repigmentation.
Patient was recalled after 1 week for re-evaluation. Wound healed uneventfully on both the sides. Patient experienced pain on the laser treated site for three days post operatively. On 1 month postoperative follow-up, the areas were completely healed (Fig-9). At 1 year follow up there were signs of repigmentation (Fig-10).

Discussion:-
Melanin pigmentation is frequently caused by melanin deposition by active melanocytes located mainly in the basal layer of the oral epithelium. Pigmentations can be removed for esthetic reasons. Different treatment modalities have been used for this aim. The selection of a technique for depigmentation of the gingiva should be based on clinical experience, patient's affordability and individual preferences. 7 Scalpel surgical technique, one of the first and most accepted, techniques to be employed was the surgical removal of undesirable pigmentation using scalpels. The procedure involves surgical removal of gingival epithelium and some part of connective tissue and allowing it to heal by secondary intention. The new epithelium that forms is without melanin pigmentation. 8 In this particular case the scalpel method of depigmentation showed better results from both clinical and patients' point of view. The area healed completely in 10 days with normal appearance of gingiva.
It is known that the healing period for scalpel wounds is faster than other techniques; scalpel surgery may cause unpleasant bleeding during and after the operation. However, it is necessary to cover the exposed lamina propria with periodontal dressing for 7 to 10 days. 9 Recently, laser ablation has been recognized as one of the most effective, comfortable and reliable techniques for gingival depigmentation. 10 The word laser is an acronym for light amplification by stimulated emission of radiation. Maiman (1960) developed the first working laser. The first application of a laser to dental hard tissue was reported by Goldman et al and Stern and Sognnaes described the effects of the ruby laser on enamel and dentin. 11 Laser was used in the gated pulsed mode. Taking into account the undue heating that could be caused to the surrounding normal and pink tissues where the melanin pigmentation was absent; a gated pulsed mode provided the necessary thermal relaxation as against using a continuous pulse mode. 12 The laser procedure was more acceptable to the patient as the procedure took less time and was more comfortable and there was absence of post-operative pain and hemorrhage. Also, from the operator's point of view, the laser technique was easier and faster to perform than the epithelial excision technique. Ribeiro et al 13 and Simşek Kaya et al 12 found similar results: That the subjects experienced a higher extent of discomfort/pain on the side treated by the scalpel technique as compared with the diode laser-treated side during the first post-therapy week. Also, the use of a diode laser presented advantages in terms of less discomfort/pain during the post-therapy period and a reduction of treatment chair time. The present study did not show any significant difference in healing of depigmented areas of the gingiva, although mild pain and inflammatory changes were seen in the surgical excision area.
Clinical reappearance of melanin pigment following a period of clinical depigmentation is known as repigmentation.
The exact mechanism of this condition is not known but according to 'migration theory', active melanocytes from adjacent pigmented tissues migrate to treated area and cause failure. However, the phenomenon of repigmentation is not universal. It might be attributed to the thoroughness of the procedure done and expertise of the clinician. 14 In the present case, certain localized areas of repigmentation were seen at the end of 1 year.
Also, Perlmutter et al 15  The success of the depigmentation procedure may be weighed only by the extent of depigmentation achieved and by the time taken for reappearance of pigments, prolonged follow-up is necessary. As the post-operative follow-up of the present study was short, it is proposed that further studies be taken up for a longer period of monitoring along with histopathological assessment to understand the process of repigmentation.

Conclusion:-
As per this study, no difference was seen in the comparison of both techniques in terms of efficiency and repigmentation. The results of this study indicated that both scalpel as well as laser was efficient for depigmentation of the gingiva. Both the procedures did not result in any post-operative complication and the gingiva healed uneventfully.