Gingival depigmentation using Er:YAG laser and scalpel technique: A six-month prospective clinical study

Gingival depigmentation using Er:YAG laser and scalpel technique: A six-month prospective clinical study

MENA Clinical Dentistry

24. January 2019

Rola Alhabashneh, Obaida Darawi, Yousef S. Khader, Lama Ashour

Objective: To compare the 6-month clinical efficacy of Er:YAG laser and standard scalpel technique in treating gingival hyperpigmentation.
Method and Materials: Patients requesting treatment for moderate to severe gingival hyperpigmentation in the maxilla were enrolled in this split-mouth study. The contralateral maxillary sides were randomly assigned to receive either Er:YAG laser (continuous wavelength of 2,940nm) with a noncontact tip or the standard scalpel technique. Dummett oral pigmentation index (DOPI) and Hedin melanin index (HMI) were compared at the baseline and at 1 and 2 weeks, and 1, 3, and 6 months following the treatment. Bleeding Index, total treatment time, patient preference, pain perception at the first 3 days, wound healing, and level of satisfaction were also compared. Mann-Whitney test, Kruskal-Wallis test, and chi-square test were used to test the significance between variables. A P value of less than or equal to .05 was considered statistically significant. Results: Of the 22 patients enrolled, 20 completed this study. After assessing DOPI and HMI at 1 and 2 weeks, and at 1-, 3-, and 6-month follow-up appointments, both Er:YAG laser and scalpel were significantly effective in treating gingival hyperpigmentation when compared to baseline (P<.001) but with no statistically significant difference between the two treatment methods (P>.05). More patients preferred the scalpel technique as it was associated with slightly shorter treatment time and less postoperative pain when compared to Er:YAG laser, but with no statistical significance (P>.05). Er:YAG laser sites showed minimal bleeding and more rapid wound healing (P<.001). Conclusion: Both Er:YAG laser and scalpel technique achieved similar outcomes regarding the efficacy of gingival depigmentation, postoperative pain perception, and the time required for the treatment. Laser therapy requires more advanced technology and is associated with higher financial costs. Therefore, the scalpel technique is still considered the gold standard treatment for gingival depigmentation. 

Introduction

Gingival health nowadays is considered an essential prerequisite for all dental work. The level of the gingiva and its color also influence the final esthetic outcome of any treatment. Normal color of the gingiva usually ranges from pale pink to violet or deep red.1 In the present authors’ experience, people who have dark or pigmented gingiva may often seek a dental consultation for esthetic purposes. Since oral pigmentation is a common finding in routine oral examination, it is important to have an exact diagnosis for the pigmented lesion before planning for the treatment. Most oral pigmented lesions represent normal physiologic changes, referred to as racial pigmentation, some represent a manifestation of systemic diseases like Addison’s disease, and rarely some may represent more pathologic or metastatic changes like melanoma.2

It is well known that melanin is the primary pigment responsible for variations in color noted with regard to complexion.3 Variation in the melanin pigmentation that is specifically seen in racial pigmentation is attributed to variations in the activity of melanocytes in the basal cell layer of the oral epithelium rather than their number; this is more common in dark-skinned individuals regardless of their ethnic background.4 Moreover, smoking is one of the most defined causes of oral pigmentation in light- and- dark-skinned individuals since melanin has a protective role against noxious agents present in tobacco smoke.5 Duration and amount of smoking are important factors that usually directly determine the intensity of pigmentation.

Several different techniques and procedures have been carried out to treat gingival hyperpigmentation including surgical removal by scalpel or burs,5, ,7  rapid freezing by cryosurgery,8,electrosurgery,10 and free gingival grafts,11 with every technique having its own advantages and disadvantages. In recent years, the introduction of lasers in the dental field has opened a wide window for modern and comfortable treatment with decreased morbidity, in an attempt to minimize patients’ discomfort and pain as much as possible.12

Using the scalpel technique to remove unesthetic gingival pigmentation is a conventional and relatively simple approach that is still considered the gold standard. It does not need sophisticated equipment and costly devices, and is easily performed under simple local anesthesia.13 This technique involves the surgical removal of the gingival epithelium and a layer of the underlying connective tissue.14 The denuded tissues heal by secondary intention, which may be associated with unpleasant bleeding during and after the procedure, with the probability of some discomfort and pain postoperatively.15

Several types of lasers are now available for dental use. The main types are Nd:YAG laser, CO2 laser, diode laser, and Er:YAG laser.16 The first three are widely used for soft tissue management, while Er:YAG laser is known for having effects on both hard and soft tissue, hence gaining recent popularity in dental clinics.17

Er:YAG laser was introduced by Zharikov et al18 in the mid-1970s, and recently cleared by the US Food and Drug Administration (FDA) in the late 1990s for some soft and hard tissue treatments.19 It has advantages among other laser types, including the potential effectiveness in hard and soft tissue, minimal heat generation with water irrigation, and no carbonization. However, the lower hemostasis ability is still a minor disadvantage.16 Er:YAG laser has a wavelength of 2,940nm, with a high absorption coefficient in water and low absorption coefficient in melanin, causing water to evaporate into steam in the tissues, resulting in microexplosions in the tissue.2

To prevent repigmentation, it has been suggested that the gingival tissue should be cleared of melanin completely, including free gingiva and interdental papilla; because repigmentation may start as a result of migrating melanocytes from these areas.15 Additionally, it has been recognized that the race and exposure to environmental tobacco smoking may contribute to an increase in the gingival pigmentation, and could be related to increase of repigmentation following successful therapy.20 The principles, techniques, and management of the problems associated with gingival melanin pigmentation are still not fully established.

The aim of this study was to compare the effects of Er:YAG laser and standard scalpel technique in treatment of gingival hyperpigmentation over a period of 6months, regarding the efficacy of depigmentation and the stability of the results in the follow-up period, hemostasis effect, postoperative pain perception and discomfort, wound healing capacity, patient preference of the techniques, and the level of patient satisfaction after the therapy.

Method and Materials

Study description

This study was a prospective blinded clinical trial with split-mouth design comparing Er:YAG laser and scalpel technique for treatment of gingival hyperpigmentation. A sample size of 20 subjects, with 40 treated sites, 20 in each arm, was sufficient to detect a mean difference of 1 unit on the rating scale between groups in reducing pigmentation assuming a standard deviation (SD) of 0.1 with 80% power and a 5% level of significance. Considering a dropout rate of 10%, the sample size required was 22 (22 per treatment group).

In the beginning, 33 patients who were referred to the Department of Periodontics at Jordan University of Science and Technology, Irbid, Jordan, complaining of unpleasant gingival pigmentation in the labial aspect of the maxilla were invited to participate in the study. After completion of the treatment, a total of 20 patients (12 females and 8 males) were followed up to a period of 6 months (Fig1). The same operator performed all surgical procedures and clinical examination. Randomization and masking were performed by preparing a box with closed envelopes, with equal distribution of the sides to receive both treatment modalities; after opening the envelope, and choosing the sides, the name of the patient was written on the envelope and was closed again until completion of all follow-up appointments. Gingival pigmentation was assessed at the follow-up appointments by direct clinical examination by the same examiner, and assigned scores based on right and left sides without knowing the technique performed on each side. At the end of the follow-up appointments, the patient’s own envelope was opened again and the scores were distributed to both treatment modalities (Er:YAG laser and scalpel) on a different paper form.

Fig 1 Study design flow chart.

Treatment protocol

All included subjects underwent initial periodontal therapy 2 weeks preoperatively, including supra- and subgingival scaling. Oral hygiene instructions were given to the patients, with chlorhexidine gluconate mouth wash (0.2%; Gargarol, Beit Jala Pharmaceutical) prescribed for 7 days. For the 22 patients included in the study, the two contralateral sites presenting melanin gingival hyperpigmentation in the anterior maxillae from the distal side of the canine to the midline were randomly assigned to receive either Er:YAG laser or scalpel technique for the esthetic treatment of gingival melanin hyperpigmentation.

The following clinical parameters were examined and followed up over the 6 months: Dummett oral pigmentation index (DOPI),21 Hedin melanin index (HMI), hemostasis effect, treatment time, pain perception at the first 3 days, patient preference, epithelialization status after 1 and 2 weeks, and level of satisfaction over a period of 6 months. DOPI was used for intensity of pigmentation and was measured before treatment, at 1 week, 2 weeks, and 1, 3, and 6 months postoperatively. HMI22 was used to define the extent of the pigmented area and was measured before treatment, at 1 week, 2 weeks, and 1, 3, and 6 months postoperatively.

The treatment time was calculated from the beginning of the surgical procedure and the first laser application, until complete depigmentation was achieved. To standardize the time period measured, a 5-minute period was assigned for the local infiltration anesthesia given to the scalpel site and for the topical anesthesia used on the laser sites.

Hemostasis effect was assessed by visual examination and based on the amount of bleeding encountered during the procedure and the difficulty of performing the procedure. It was assessed on the following scale:

no bleeding, complete homeostasis

isolated bleeding points during surgery (mild)

moderate bleeding, but clear field

severe bleeding, difficulty in procedure.23

All patients were called by their mobile number on the evening of the operation day (day 1), day 2, and day 3 postoperatively, and were asked to mark the level of pain experienced based on the 0 to 10 numeric pain rating scale (visual analog scale), with the left end (0) point marked “no pain” and the right end (10) marked “severe pain.” A mark was placed at the corresponding number to match with the level of pain experienced. Scores were calculated as:

0, no pain

1 to 3, mild pain,

4 to 6, moderate pain

7 to 10, severe pain.24

In case the pigmentation extended further distal to the canine, it was removed without measuring the time required for the further procedure. Postoperative oral hygiene instructions were given to the patient, and they were instructed to avoid smoking and eating hot and spicy food for the first 24 hours.

The same operator performed in one visit all treatments. At the end of the procedures, all patients were instructed to use paracetamol 500mg four times a day when needed in case of pain. Patients were also instructed to use chlorhexidine gluconate (0.2%, Gargarol) mouth wash in the first postoperative week. If the patient had gingival pigmentation on the mandibular gingiva, it was depigmented in a later appointment with the preferred method, but was not included in the study.

Er:YAG laser site

For sites treated with laser, benzocaine 20% as topical anesthesia in the form of gel (Ultracare, Ultradent Products) was applied for 5 minutes from the midline distally in the laser site, and an Er:YAG laser device (Doctorsmile Pluser laser, Lambda Scientifica) with a continuous wavelength of 2,940nm was applied at 1W via a sapphire tip (diameter 800 μm; length 12mm) in a fiber-optic handpiece. The procedure was performed with the handpiece at a distance of 5mm from the gingiva in a noncontact mode and from a cervical-apical direction in a brush stroke pattern until the entire area was completely depigmented. The operative site was cooled using 50% air spray and 50% water spray.

Scalpel technique sites

Lignocaine hydrochloride (2%) with 1:100,000 adrenaline (Octocaine 100, Novocol Pharmaceutical) was administered by infiltration of the scalpel-treated area from the midline distally. After a 5-minute period, the anesthesia was checked. Partial dissection or peeling of the affected area was performed using blade no. 15c. If the papilla was pigmented, it was also de-epithelized to avoid a migration effect of the melanocytes. The surgical site was irrigated frequently with normal saline during the procedure, and a gauze pressure pack was given to the patient to control the bleeding if present. No periodontal dressing was placed.

Data management and statistical analysis

The data were coded and entered in a Microsoft Excel sheet, imported and analyzed using SPSS (IBM, v23.0). Mann-Whitney U test was used to check the level of significance between the two study groups regarding the DOPI, HMI, Bleeding Index, chair time, and wound healing index. Within study groups, differences between the three times (baseline, and 3 and 6 months following intervention) were analyzed using Kruskal-Wallis test. Association between patient preference and degree of satisfaction was checked using chi-square test. A P value of ≤.05 was considered significant for all tests.

Results

A total of 20 subjects successfully completed the study period of 6 months and were included in the data analyses. All 20 participants maintained the recall visits at 2and 6 months (Fig2).

Changes in DOPI

As displayed in Tables1 and 2, no statistical difference was found between both groups at the baseline regarding the DOPI and HMI measurements (P=.752 and 1.000), respectively.

Table 1 Mean values of DOPI at different observation times in both groups

Time Laser, mean ± SD Scalpel, mean ± SD P value†
Baseline 2.45 ± 0.51a 2.40 ± 0.50a 752
1 week 0.00 ± 0.00 0.00 ± 0.00 NA
2 weeks 0.00 ± 0.00 0.00 ± 0.00 NA
1 month 0.00 ± 0.00 0.00 ± 0.00 NA
3 months 0.20 ± 0.41b 0.15 ± 0.37b 681
6 months 0.30 ± 0.47b 0.20 ± 0.41b 471
P value‡ < .001* < .001*

NA, not applicable.

*Statistically significant P < .05. †Row-wise comparisons are carried out using Mann-Whitney’s test.

‡ Column-wise comparisons were carried out using Kruskal-Wallis test.

ab Superscript letters indicate significantly different means (P < .05) within laser and scalpel group separately.

Table 2 Mean values of HMI at different observation times in both groups

Time Laser, mean ± SD Scalpel, mean ± SD P value†
Baseline 3.40 ± 0.50a 3.40 ± 0.50a 1.000
1 week 0.00 ± 0.00 0.00 ± 0.00 NA
2 weeks 0.00 ± 0.00 0.00 ± 0.00 NA
1 month 0.00 ± 0.00 0.00 ± 0.00 NA
3 months 0.20 ± 0.41b 0.15 ± 0.37b 681
6 months 0.35 ± 0.59b 0.20 ± 0.41b 429
P value‡ < .001* < .001*

NA not applicable.

* Statistically significant P < .05.

† Row-wise comparisons are carried out using Mann-Whitney’s test.

‡ Column-wise comparisons were carried out using Kruskal-Wallis test.

ab Superscript letters indicate significantly different means (P < .05) within laser and scalpel group separately.

At the 1-week, 2-week, and 1-month appointments, all the sites were free from any pigmentation and the DOPI measurements were 0.00 at all Er:YAG laser and scalpel sites.

At 3 months, 16 patients (80%) had grade 0, and four patients (20%) had grade 1 at the Er:YAG (2,940nm) laser sites. Seventeen patients (85%) had grade 0, and three patients (15%) had grade 1 at the scalpel sites. Both groups showed a positive result regarding the gingival depigmentation treatment without significant difference between them (P=.681).

At 6 months, 14 patients (70%) had grade 0, and 6 patients (30%) had grade 1 at the Er:YAG (2,940nm) laser sites. Sixteen patients (80%) had grade 0, and four patients (20%) had grade 1 at the scalpel sites. No significant difference was found between both treatment modalities at the 6-month appointments (P=.471)

Changes in HMI

At the 1-week, 2-week, and 1-month appointments, all the sites were free from any pigmentation and the HMI measurements were 0 at all Er:YAG laser and scalpel sites.

At 3 months, 16 patients (80%) had grade 0, and four patients (20%) had grade 1 at the Er:YAG (2,940nm) laser sites. Seventeen patients (85%) had grade 0, and three patients (15%) had grade 1 at the scalpel sites. Both groups showed a positive result regarding the gingival depigmentation treatment without significant difference between them (P=.681).

At 6 months, 14 patients (70%) had grade 0, five patients (25%) had grade 1, and one patient had grade 2 (5%) at the Er:YAG (2,940nm) laser sites. Sixteen patients (80%) had grade 0, and four patients (20%) had grade 1 at the scalpel sites. No significant difference was found between both treatment modalities (P=.429).

Total treatment time (chair time)

A longer treatment time was observed in the Er:YAG laser sites (11.9 minutes) than in the scalpel sites (11.2 minutes), but the comparison between groups was not statistically significant (P=.459).

Bleeding during the procedure

The mean scores of Bleeding Index for Er:YAG laser sites and the scalpel sites were 1.05 and 1.80 respectively. There was a statistically significant difference between the groups regarding the Bleeding Index (P<.001).

Pain perception postoperatively

As shown in Table3, the mean scores for pain using a 0 to 10 horizontal numeric scale at days 1, 2, and 3 were 1.75, 1.00, and 0.00 respectively for the Er;YAG laser sites, and were 1.30, 0.75, and 0.00 respectively for the scalpel sites. No significant differences were found between the groups regarding the pain perception at the first 3 days after treatment (P>.05). Only two patients reported using analgesics after treatment.

Table 3 Mean values of pain perception using 0 to 10 numeric pain scale at the first 3 days postoperatively for the two study procedures

Time Laser, mean ± SD Scalpel, mean ± SD P value
Pain scale day 1 1.75 ± 1.52 1.30 ± 1.45 328
Pain scale day 2 1.00 ± 1.45 0.75 ± 1.25 640
Pain scale day 3 0.00 ± 0.00 0.00 ± 0.00

Patient preference

From the total of 20 patients, 11 (55%) patients preferred the scalpel technique, and nine (45%) gave first preference to the Er:YAG laser technique. The comparison was not statistically significant (P=.40) (Fig3).

Fig 3 Percentage of patient preference for the two study techniques.
 Wound healing and degree of epithelialization

At the 1-week follow up (Fig4), for the Er:YAG laser sites, only two patients (10%) showed complete epithelialization and 18 patients (90%) showed incomplete epithelialization. For the scalpel sites, none of the patients showed complete epithelialization, whereas two patients (10%) showed small unhealed ulcers. The difference between the groups at the 1-week follow-up was statistically significant (P=.048),

Fig 4 Percentage of patients showing different healing status at 1 week postoperatively for the two study techniques.

At the 2-week follow-up, all patients (100%) showed complete epithelialization at the Er:YAG laser sites, while in the scalpel sites 18 patients (90%) showed complete epithelialization, and two patients (10%) showed incomplete epithelialization. However, the comparison was not statistically significant (P=.152) (Fig5).

Fig 5 Percentage of patients showing different healing status at 2 weeks postoperatively for the two study techniques.

 

Patient satisfaction

After 6 months of follow-up, 15 patients (75%) selected the choice “very satisfied” for both sides, and the remaining five patients (25%) selected the choice “satisfied” for both sides. None of the patients chose the options “neutral” or “unsatisfied” for any treatment site. The comparison regarding patient satisfaction level was not statistically significant (P=1.00).

Discussion

Both the Er:YAG laser and scalpel techniques provided satisfactory results regarding the efficacy of gingival pigmentation removal immediately after the procedure in terms of DOPI and HMI, and the gingiva became completely pink at the 1-week, 2-week, and 1-month appointments.

Regarding the treatment time, scalpel technique showed slightly less treatment time than Er:YAG laser, but the difference was not statistically significant. This may be attributed to the shallow surface interaction of the Er:YAG laser, which means more laser passage is required to irradiate the site and consequently more chair time; it may also be attributed to the clinician’s skill in using the laser. This was also a finding of Giannelli et al25 and Kishore et al (26) , who noticed that the Er:YAG laser required more time than the diode laser to treat gingival hyperpigmentation when compared to other laser types.

Er:YAG laser lacks any coagulation effect and hence a slight to moderate degree of bleeding was encountered during the procedure. However, this bleeding could be controlled easily, unlike with the scalpel technique, for which it was more difficult to control the degree of bleeding during the treatment.

Regarding pain perception, slightly more pain was encountered in the Er:YAG laser sites, and this can be attributed to the shallow surface interaction of the laser beam that required repeated passages, with the increased the risk of causing damage to the lamina propria and consequently more postoperative pain.25 Another possible reason could be the lasting effect of local anesthesia at the surgical sites at the first day compared with topical anesthesia at the contralateral laser sites, and this finding is in agreement with Kaya et al,27 who found an average pain score of 1.0 in the Er:YAG laser group and recommended using a low power setting on a weekly basis until complete depigmentation was achieved, instead of a single session. Rosa et al23 also recommended a second irradiation of Er:YAG laser 4 days after the first session.

It was noted that more patients preferred the surgical method to the laser technique. They felt that the procedure was quiet and ordinary, and they did not experience any pain or discomfort other than the injection. Patients who preferred Er:YAG laser appreciated that no anesthesia was required during the treatment, and also appreciated the absence of postoperative bleeding. A few patients, however, complained of the bullet-sound of the laser machine. This finding contradicted the result obtained by Hegde et al,28 who found that significantly more patients favored the Er:YAG laser technique than surgical stripping or CO2 laser.

Regarding wound healing, all patients had a normal gingival appearance, and no hemorrhaging, morphologic abnormalities, scarring, or infection in the treated area was observed at any time during the observation period. At the 1-week appointment, the Er:YAG laser showed significantly faster wound healing. Nearly all cases showed complete epithelialization by the second week, except two cases from the scalpel group which had partial epithelialization. The improvement in the wound healing that was noticed in the Er:YAG laser group may be explained by the bactericidal effect, related to the generation of reactive oxygen species in irradiated tissue, which may have sterilization effects, stimulate fibroblasts, and cause collagen and extracellular matrix formation.29 Also, less thermal damage is associated with this type of laser.30 This finding is supported by a study by Azzeh,31 who found rapid healing by the fourth day after treatment with Er:YAG laser, and Tal et al,32 who reported gingival healing after 10 days of Er:YAG irradiation.

Results of both treatment modalities were stable to some extent, with slight recurrence seen as solitary units of pigments mainly in the papillary area in both sites at 3 and 6 months. The difference in repigmentation was not significant but was slightly more in the Er:YAG laser group than in the scalpel group. This can be attributed to the shallow penetration depth of this type of laser,23,25 and the consequent increased number of melanocytes remaining deep in the gingival tissue that may have become activated and started synthesizing melanin.33

A reason for the increase in the repigmentation in the papillary areas in both groups could be the difficulty in completely removing the melanin pigments from these sites and the increasing thickness of papillary tissue. This was in agreement with Esen et al,34 who found that the papillary area and gingival margins were the most repigmented sites after treatment with CO2 laser.

At the end of the follow-up period, most patients in both groups were highly satisfied with the results. Although some cases presented with areas of repigmentation, this had a minimal effect that did not affect the level of patient satisfaction.

Conclusion

In conclusion, the present study demonstrated that both the Er:YAG laser technique and the scalpel technique used for gingival depigmentation may achieve similar outcomes, as measured by Dummet oral pigmentation index, Hedin melanin index, postoperative pain perception, the required time for the treatment, and the amount of recurrence. Laser therapy requires a more advanced technology and is associated with higher financial costs than the use of the scalpel technique,35 which is more economical. Therefore, it can be concluded that the scalpel technique will remain the “gold standard” treatment technique for gingival depigmentation.

References

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Notes
  • 1 Jones J, Mcfall WT. A photometric study of the color of healthy gingiva. J Peridontol 1977;48:​21–26.
  • 2 Kauzman A, Pavone M, Blanas N, Bradley G. Pigmented lesions of the oral cavity: review, differential diagnosis, and case presentations. J Canad Dent Assoc 2004;70:​682–683.
  • 3 Brunsting LA, Sheard CH. The color of the skin as analyzed by spectrophotometric methods. J Clin Investig 1929;7:​593–613.
  • 4 Feller L, Masilana A, Khammissa RAG, Altini M, Jadwat Y, Lemmer J. Melanin: the biophysiology of oral melanocytes and physiological oral pigmentation. Head Face Med 2014;10:​1–7.
  • 5 Hedin CA, Axéll T. Oral melanin pigmentation in 467 Thai and Malaysian people with special emphasis on smoker’s melanosis. J Oral Pathol Med 1991;20:​8–12.
  • 6 Tanuja P, Butchi BK, Murali KT. Laser-assisted crown lengthening and gingival depigmentation to enhance aesthetics-a case report. Ann Essences Dent 2011;3:​56–59.
  • 7 Shah SS. Surgical esthetic correction for gingival pigmentation: case series. J Interdiscip Dent 2012;2:​195–200.
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Authors

Rola Alhabashneh, BDS, MS, MPH, AB perio1

Obaida Darawi, BDS, MClinDent2

Yousef S. Khader, BDS, MSc, MSPH, MHPE, FFPH, ScD3

Lama Ashour, BDS2