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CASE REPORT

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ESTHETIC TREATMENT OF HYPERPIGMENTED

GINGIVA BY SCALPEL AND LASER: A

COMPARATIVE CASE REPORT

Dr.Indumathi P, Dr.Ramakrishnan.T, Dr.Dhivya R, Dr.Shivaranjani.P, Dr.Irudhaya Nirmala.J

Department of Periodontology, Adhi Parasakthi Dental College & Hospital, Melmaruvathur, Tamilnadu, India.

ABSTRACT

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BACKGROUND: Melanin pigmentation in the gingiva

occurs as a result of excess deposition of melanin, due to

which the gingiva appears black. Many people complain of

dark gums as unesthetic. Gingiva is the most frequently

pigmented intraoral tissue, more pigmentation concentrated

in the incisor region which may interfere with the smile

line and patient may feel conscious about the appearance.

In such patients, esthetic periodontal plastic surgery can

give excellent results.

CASE REPORT: In this case report we have attempted and

compared, two different depigmentation techniques using a

semi-conductor diode laser technique in maxillary anterior

arch and conventionally by scalpel technique in mandibular

DOI:10.37841/jidam_2020_V7_I2_02

Address for correspondence:

anterior arch.

RESULT: Both scalpel and laser improved esthetics. However

Dr. Indumathi.P

the laser treatment resulted in no post-operative bleeding and

Post Graduate, Department of Periodontology,

no post-operative pain as compared with scalpel technique.

Adhi Parasakthi Dental College & Hospital,

Melmaruvathur, Tamilnadu, India.

CONCLUSION: Use of diode laser is the safe and effective

alternative procedure for the treatment of hyperpigmented

Email id: indukutty523@gmail.com

gingiva. Its benefits include ease of usage, comfort in dental

clinics, reduce trauma to the patient.

KEYWORDS: Diode laser, Depigmentation, Melanin pigment.

Received

: 27.03.2020

Accepted

: 17.05.2020

Published

: 27.06.2020

JIDAM/Chennai/Volume:7/Issue:2/Pages 58 - 62/April-Jun 2020

Indhumathi et al: Esthetic Treatment of Hyperpigmented Gingiva By Scalpel And Laser

INTRODUCTION:

CASE REPORT:

The gingival color is determined by

A 23 years old male patient reported to the

various factors such as blood vessels, epithelial

Department of Periodontology, Adhiparasakthi

thickness, keratinization quantity and presence

Dental College and Hospital with the chief

of pigments within the gingival epithelium¹.

complaint of black discoloration of his gums

The color of attached and marginal gingiva is

since he was very concerned about the esthetic

generally described as coral pink². Melanin is

appearance. Intraoral examination revealed no

a brown pigment, the most common natural

dental abnormalities other than pigmentation in

pigment contributing to endogenous pigmentation

maxillary and mandibular gingiva (Fig 1). The

of the gingiva³. Melanin pigmentation is the result

pigmentation was displeasing for the patient so a

of melanin granules produced by melanoblasts

treatment plan of depigmentation was proposed.

interwined between epithelial cells and basal

After obtaining patient′s consent, treatment

layer of gingival epithelium⁴. Pigmentation of the

was initiated. Phase I therapy included routine

gingiva occur in all ethinicities⁵. But high levels

blood investigation and as all values were within

of oral pigmentation are observed in individuals

physiological limits, scaling was done and the

of African and East Asian. The distribution of

patient was recalled after a week for depigmentation

pigmentation in oral cavity in black individuals is

procedure.

as follows: gingiva 60%, hard palate 61%, mucous

membrane 22% and tongue 15%. Gingival pig-

mentation occurs as a diffuse, irregularly shaped

brown to light-brown patch. It may appear in the

gingiva as early as 3 hours after birth. Pigmentation

of gingiva can caused by local and systemic factors

such as antimalarial therapy, malignant melanoma,

Peutz- Jeghers syndrome, Albright’s syndrome,

trauma, endocrine disturbances hemachromatosis,

chronic pulmonary disease and racial pigmentation

are the identified causes of oral

melanin

pigmentation⁶. The gingival hyperpigmentation

is treated by various techniques and the selection

of technique based on clinical experiences and

Fig 1: Preoperative view

individual preferences with demand for improved

esthetics. Different techniques for depigmentation

PROCEDURE:

include⁷:

DEPIGMENTATION WITH LASER:

1. Scalpel

2. Cryosurgery

After application of topical anesthesia

3. Electrosurgery

(Lignocaine 2% gel) on maxillary anterior region,

4. Chemical method

the diode laser with power settings of 1-1.5 watts

5. Masking the pigmented gingiva

with continuous mode was used to remove the

a. Free gingival graft

pigmented epithelium (Fig 2). The laser tip was

b. Acellular dermal matrix allograft

used with brushing strokes and high volume suction

6. Lasers - Nd: YAG laser, Er: YAG laser, CO2 laser

was used to evacuate the laser plumes. Tissue tags

were removed using wet gauze (Fig

3). During

Recently, laser ablation has been recognized

the procedure, patient, surgeon and assistant were

as a most effective, pleasant and reliable technique.

advised to wear protective eyewear to fulfill the

FDA measures. Patient was comfortable from

The present case series describes a

the beginning till the end of the treatment. Post

comparative evaluation of treating

gingival

operative instructions were given and patient was

pigmentation using scalpel and diode laser technique.

recalled after 7^th and 15^th day for review (Fig 4).

JIDAM/Chennai/Volume:7/Issue:2/Pages 58 - 62/April-Jun 2020

Indhumathi et al: Esthetic Treatment of Hyperpigmented Gingiva By Scalpel And Laser

prescribed along with the chlorhexidine mouth wash.

The patient was recalled after 7^th and 15^th day for

review (Fig 8).

Fig 2 : Use of diode laser

Fig 5: Use of Scalpel technique

Fig 3: Immediate post operative view

Fig 6: Immediate postoperative view

Fig 4: Post operative view after 15 days

DEPIGMENTATION WITH SCALPEL

Fig 7: Surgical site covered with periodontal dressing

TECHNIQUE:

After infiltration of local anesthesia in the

mandibular anterior region, depigmentation was done

using scalpel method. Depigmentation was carried

out from the mucogingival junction to the interdental

papilla with BP blade No 15 (Fig 5). Care was taken

to avoid pitting of gingival surface or to remove

excess tissue. The entire pigmented epithelium was

removed and was ensured that of pigmented layer

were removed (Fig 6), pressure was applied with

Fig 8: Post operative view after 15 days

a sterile gauze moistened with saline to control

bleeding. Thorough saline irrigation was done and the

Patient was reviewed on 7^th and 15^th day

surgical area was covered with periodontal dressing

and VAS were recorded to compare between laser

(Fig 7). Post surgical antibiotics and analgesics were

method and scalpel method pre and post operatively

(Fig 9 and Fig 10).

JIDAM/Chennai/Volume:7/Issue:2/Pages 58 - 62/April-Jun 2020

Indhumathi et al: Esthetic Treatment of Hyperpigmented Gingiva By Scalpel And Laser

Clinical evaluation of pain visual analog scale:

fiber optic delivery system. Laser light at 800-980nm

is poorly absorbed in water but highly absorbed in

Method

Immediate

Postop -

Postop

hemoglobin and other pigments. The diode laser is

an excellent soft tissue laser indicated for cutting,

post op

1 day

-15 days

coagulating gingival and oral mucosa and for soft

Surgical

tissue curettage or sulcular debridement. The diode

Laser

laser exhibits thermal effect using the “hot tip” effect

caused by heat accumulation at the end of the fiber,

and produces a relatively thick coagulation layer on

the treated surface, it does not produce any harmful

effect on root surface¹⁰.There are many advantages of

lasers over surgical procedures. According to Wigdor

et al (1995) these include:

•

Dry and bloodless surgery

•

Instant sterilization of the surgical site

•

Reduced bacteremia

•

Reduced mechanical trauma

•

Minimal postoperative swelling and scar

Fig 9 : Pre operative view

•

Minimal postoperative pain

The use of lasers can reduce patients anxiety

or fear of drill. It provides a ‘needle-free’ approach or

no anesthesia dentistry. Also, laser dentistry requires

less chair-side time compared to more traditional

treatments. The diode laser has the unique property

of being able to remove a thin layer of epithelium

cleanly and it causes minimal damage to periosteum

and bone under the gingiva being treated¹¹. In this

present case report the laser technique found to be

effective than the scalpel technique, since the patient

has less post operative pain and discomfort in the

Fig 10 : Post operative view

site treated by diode laser which was proved by VAS

score. However the healing period of scalpel wound

DICUSSION:

is shorter than with diode laser, it causes unpleasant

bleeding during and after the procedure and it is

Melanin pigmentation is frequently

caused

necessary to cover the surgical site with periodontal

by melanin deposition by active melanocytes⁸.

pack .

Pigmented gingival tissue often forces patient to seek

cosmetic treatment. Several techniques have been

CONCLUSION:

suggested for treating the gingival pigmentation.

In this present case report, both the scalpel and

Gingival depigmentation is most often

laser technique was used. To date numerous lasers

a patient demanded esthetic treatment. In this

systems are available for both soft and hard tissue,

current case report, both scalpel and laser was

like neodymium-doped yttrium-aluminum-garnet

found to be effective in the treatment of gingival

(Nd:YAG) carbon dioxide

(CO2),semiconductor

hyperpigmentation, however laser being more

diode lasers, erbium-doped yttrium-aluminum-garnet

patient friendly. Thus laser ablation for gingival

(Er:YAG) laser⁹. The semiconductor diode laser is

depigmentation has been recognized as one of the

emitted in continuous wave or gated pulse mode and

most effective, pleasant and reliable techniques⁹ that

usually operated in a contact method by using flexible

offers bloodless, painless, and sterile field with better

patient compliance and satisfaction.

JIDAM/Chennai/Volume:7/Issue:2/Pages 58 - 62/April-Jun 2020

Indhumathi et al: Esthetic Treatment of Hyperpigmented Gingiva By Scalpel And Laser

FINANCIAL SUPPORT AND

evaluation with a case report. Int J Laser

SPONSORSHIP:

Dent. 2013;3(2):68-72.

Bhardwaj A, Grover HS, Lal S. Gingival

Nil

depigmentation with scalpel and diode laser.

World journal of dentistry. 2012 ;3(4):359-62.

CONFLICTS OF INTEREST:

10.

Bakutra G, Shankarapillai R, Mathur L,

There are no conflicts of interest.

Manohar B. Comparative evaluation of diode

laser ablation and surgical stripping technique

REFERENCES :

for gingival depigmentation: A clinical and

immunohistochemical study. International

Kathariya R, Pradeep AR. Split mouth

journal of health sciences. 2017 ;11(2):51.

de-epithelization techniques for gingival

11.

Sanadi DR, Suthar DN, Bhusari DB, Chelani

depigmentation: A case series and review

DL. Gingival Depigmentation Using Scalpel

of literature. Journal of Indian Society of

Technique versus Laser Technique: A Case

Periodontology. 2011 : 15(2):161.

Report. IOSR Journal of Dental and Medical

Newman MG, Takei H, Klokkevold

Sciences. 2015 :2279-0853.

PR, Carranza FA. CarranƵa’s clinical

periodontology. Elsevier health sciences;

2011:14.

Grover HS, Dadlani H, Bhardwaj A, Yadav

A, Lal S. Evaluation of patient response and

recurrence of pigmentation following gingival

depigmentation using laser and scalpel

technique: A clinical study. Journal of Indian

Society of Periodontology. 2014;18(5):586.

Patil KP, Joshi V, Waghmode V, Kanakdande

V. Gingival depigmentation: A split mouth

comparative study between scalpel and

cryosurgery. Contemporary clinical dentistry.

2015;6.

Ladvige S, Doshi Y, Marawar P. Management

of gingival hyperpigmentation using scalpel

and diode laser: A comparative study. J Oral

Laser Appl. 2009;9:41-7.

Renganath MJ, Ramakrishnan T, VidyaSekhar

MN, Ebenezer M, Anithadevi S. Black to

Pink: A Case Report of Treating Gingival

Hyperpigmentation. Int J Cur Res Rev 2017

1;9(3):14.

Murthy MB, Kaur J, Das R. Treatment of

gingival hyperpigmentation with rotary

abrasive, scalpel, and laser techniques: A

case series. Journal of Indian Society of

Periodontology. 2012 ;16(4):614.

Kaushik N, Srivastava N, Kaushik M,

Gaurav V. Efficacy of different techniques

of gingival depigmentation: a comparative

JIDAM/Chennai/Volume:7/Issue:2/Pages 58 - 62/April-Jun 2020