Comparative Evaluation of Gingival Depigmentation by Scalpel, Electrosurgery, and Laser: A 14 Months’ Follow-up Study

INTRODUCTION

There are several factors that determine the beauty of an individual’s smile. One of the most imperative but often overlooked factor is gingival esthetics that could significantly enhance the smile and confidence of the individual. Gingival esthetics is a decisive factor in smile design.¹ Beauty of the smile mainly revolves around gingival zenith,² but the color of the gingiva can significantly influence the outcome of the smile design especially in individuals with high lip line and gummy smile.³ The physiologically ideal color of the gingiva is salmon pink, which can vary depending upon the intensity and depth of melanin pigmentation that is more prominent in Asians and blacks compared to Caucasians.⁴ Pigmentation in the gingiva and oral cavity could be physiological or pathological and affected by a plethora of local and systemic factors like use of tobacco products and long-term use of certain medications like antimalarial medication or antidepressants.⁵ The physiological color of gingiva is due to a combination by different types of pigments like melanoid, carotene, reduced hemoglobin, soft keratin, and oxyhemoglobin.⁶ Hyperpigmentation of the gingival tissues occurs when melanocytes deposit excessive amount of melanin concentrated mostly to the basal and suprabasal cell layers of the epithelium.⁷ Gingival color is not uniform and varies from person to person and it has been observed that hyperpigmentation is normally found in individuals of African, East Asian, or Hispanic ethnicity.⁸ Positive correlation of skin color and gingival pigmentation among a sample of South Indian population has been documented where the authors further state that the pigmentation was more in the attached gingiva and interdental papilla.^6,9 Although gingival hyperpigmentation per say is not a disorder or disease, it poses an esthetic challenge for an individual with gummy smile.¹⁰ Various treatment strategies and protocols have been successfully employed for depigmentation of the gingiva such as use of a rotary bur or surgical scalpel to scrape the gingival epithelium, use of free gingival grafts, electrocautery, cryotherapy, local application of chemical agents, and soft tissue dental lasers.^11–14 Although several studies suggest laser ablation as a preferred treatment for gingival depigmentation,¹⁵ there are contradictive reports on the repigmentation rate post laser ablation as compared to the traditional scalpel method.¹⁶ There still exists lacunae in this regard; hence, the aim of the study was to compare three different techniques using scalpel, electrosurgery, and laser for gingival depigmentation in terms of pain, discomfort, duration of procedure, would healing, and repigmentation.

MATERIALS AND METHODS

Total 30 systemically and periodontally healthy individuals in the age range of 24–38 years with hyperpigmented gingiva were recruited for the study upon obtaining a written informed consent. The study was performed from May 2018 to March 2020 at Bharathirajaa Hospital and Research Institute, Chennai.

RESULTS

A statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 21.0 for windows). For qualitative variables, mean and standard deviation were calculated. In the present study, out of the total 30 patients treated (age group 24–38 years), 15 were males and 15 were females. All the patients had good oral hygiene at baseline as assessed by the OHI-S index. Gingival pigmentation was assessed using the Dummett-Gupta oral pigmentation index and all patients has a uniform score of 3 at baseline. All patients tolerated the procedures well, but patients of group I and group II complained of pain initially days following the procedure, particularly while eating or drinking. The VAS scores of patients in all the groups are presented in Table 1 (scalpel), Table 2 (electrosurgery), and Table 3 (laser). The analysis showed a statistically significant difference in the pain levels between group I and group III 2 hours, 24 hours, and 1 week postoperatively (p < 0.001, Student’s t-test), with the laser group demonstrating less pain (Fig. 4). Group III demonstrated less pain and discomfort at all the time intervals compared to group I and group II. The average time taken to perform depigmentation in group I was 28 minutes and 30 seconds, in group II it was 17 minutes and 20 seconds, and in group III it was 15 minutes and 45 seconds. There was no significant difference in time taken for treatment between group II and group III, whereas compared to group I there was significant reduction in time taken to perform the treatment. Clinical evaluation of wound healing as assessed by the peroxide test is represented in Table 4. Postoperatively delayed healing was observed in the electrosurgically and scalpel-treated site. The peroxide test was positive on 1st week and 2nd week postoperatively for both group I and group II (Table 4). After 1st week, slight redness was observed around the margins of the surgical site treated by a conventional technique whereas the site treated with electrosurgery showed generalized reddened areas. Better healing at laser-treated sites (group III) was clinically appreciable. Lesser time for healing in laser-treated sites (group III) could have contributed to decreased postoperative discomfort to the patients. All treated sites healed well after 1 month irrespective of treatment method used. Healed gingiva epithelium did not show signs of melanin pigmentation. Clinical examination of gingiva showed a pale pink appearance. All the patients were satisfied with the outcome. Total 8 out 10 patients in group I, 7 out of 10 patients in group II, and 2 out of 10 patients in group III showed repigmentation at the end of 14 months.

DISCUSSION

Gingival melanin pigmentation can play a pivotal role in esthetic of an individual’s smile. Many a time excessive pigmentation of the gingiva has physiological causes than pathological conditions. This has made the condition very prevalent in country like India where accentuated racial pigmentation is the most common complaint with which patients approach the dentist. Various periodontal plastic surgical techniques have been employed to remove gingival hyperpigmentation such as abrasion by bur, electrosurgery, cryosurgery, scalpel, and lasers. Even with the advancements in dental armamentarium, the use of surgical scalpel is still the preferred and more commonly used technique owing to its ease of use and economy compared to other techniques.²² However, the use of electrocautery and laser as techniques to achieve gingival depigmentation is also employed for their ease and advancement as a surgical technique. With regard to postoperative pain assessment, the VAS is a well-established tool despite its inbuilt demerits of being a subjective tool.^23,24 The hydrogen peroxide test, which is a clinical maneuver to test complete epithelization of surgical wounds, was also followed in this study. The present study was performed with the prime aim of comparing three commonly employed techniques, namely scalpel, electrosurgery, and laser for depigmentation in patients who had accentuated physiological gingival pigmentation and also to compare the techniques based on pain, discomfort, duration of procedure, would healing, and repigmentation.

With regard to time taken for completing the procedure, it was found that the laser technique consumed the least time of 15 minutes 45 seconds compared to electrosurgery that consumed 17 minutes and 20 seconds and the scalpel technique that took 28 minutes and 30 seconds. This finding is justifiable as laser is an efficient technique to perform surgical procedures. It can be controlled well by the operator in comparison to the scalpel technique where the depth of penetration cannot be controlled. Also, bone charring and an offensive smell make electrocautery less acceptable than the laser technique. In this study, it was observed that there was not a significant procedural time difference when laser and electrosurgery techniques were compared with each other.

The postoperative pain was assessed at 2, 24, and 168 hours (1 week) in the present study. Findings revealed that the patients who underwent laser depigmentation had least postoperative pain at all the three assessment times using the VAS, which is a globally accepted pain scale.

The study demonstrated delayed epithelialization in scalpel and electrosurgically treated sites compared to laser, based on the hydrogen peroxide test. The connective tissue bed beneath the epithelium contains enzyme catalase, which upon interaction with H₂O₂ releases H₂O and O₂, which clinically represents as bubbling in the healing site.²² In situations where the epithelial barrier is intact, H₂O₂ does not reach the connective tissue bed and hence clinically there is no bubble formation. Studies comparing the healing of surgical would by scalpel and electrosurgery have shown to have conflicting results. Some studies showed no significant differences in gingival healing after electrosurgery and conventional scalpel surgery. Tipton et al.²⁵ demonstrated that surgical would with a scalpel is stronger and heals faster than electrosurgically induced wound. Manivannan et al.²⁶ stated that in electrosurgery sites there could be decreased blood flow contributing to delay in the healing process. The superior results obtained with regard to wound healing in the laser group can be in part explained by the beneficial effects of laser on many aspect of wound healing such as angiogenesis, stimulation of fibroblasts, epithelial cells, and inhibition of collagen degradation.

The success of a surgical procedure depends on the less recurrence rate of the condition treated. In this regards also, laser stood out as a technique with least reoccurrence rate of repigmentation of 20% in contrast to scalpel (80%) and electrosurgery (70%).

Laser is a noninvasive method that can be performed by application of topical local anesthetic gel. It causes minimum damage to the underlying hard tissues. Laser beam has the potential to destroy the epithelial cells up to the basal layer. This could probably reduce the rate of repigmentation as compared to other techniques.²⁷ Laser beam targeted upon the pigmented lesions strike the melanocytes. Diode lasers are well absorbed by melanin and the light energy is converted to heat energy by photothermolysis. The diode lasers release their thermal effects by the hot tip effect due to accumulation of heat at the tip of the fiber; hence, the tip of the laser fiber is the cutting surface. Lasers also allow us to control the cutting efficiency as this is determined by the inherent ability to be absorbed within the chromophores with a specific target tissue and, thus, cause a tissue-specific ablation layer by layer and cell by cell.²⁸ In the present study, the laser group patients reported less pain and discomfort compared with the electrosurgery group and the scalpel group. This can be attributed to the fact that diode laser can have an analgesic effect by disrupting the sodium and potassium pump in the cell membrane, thereby the impulses are not transmitted or merely due to the formation of a protein coagulum by ablation of the nerve endings.²⁹ The advantages of lasers over other surgical techniques are: (a) ability to perform surgery with topical application of local anesthetic gel, (b) bloodless and dry surgical site, (c) immediate sterilization of the surgical site, (d) reduced mechanical trauma, minimal or no swelling, pain and scarring postoperatively.³⁰

The limitation of the study is mainly the fact that a split-mouth design was not implemented to compare the three techniques of depigmentation. This can be justified as a split-mouth design would complicate the procedures and also consume more chairside time. Hence, it was not followed.

CONCLUSION

The rising concern for esthetic demand of an individual requires the removal of hyperpigmented gingival areas to create a confident and pleasing smile, which could be easily attained by using laser. This study concludes that laser is an effective and fast tool that causes less pain, discomfort, faster healing, and delayed repigmentation compared with scalpel or electrosurgery for gingival depigmentation.

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