Evaluation of Electrosurgery and Diode Laser in Gingival Depigmentation.

Introduction: Gingival depigmentation is a surgical procedure done to eliminate or reduce gingival hyperpigmentation. Various techniques are employed such as scalpel de-epithelization, gingivectomy, electrosurgery, use of chemical agents, cryosurgery, and lasers. The present study was conducted to assess the efficacy of laser and electrosurgical procedure in reducing gingival pigmentation in terms of pain, wound healing, and recurrence of melanin pigmentation. Methodology: A prospective study was conducted on 40 subjects affected by melanin pigmentation. Group I patients were treated with electrosurgery and Group II patients with diode laser procedure. Evaluation for pain was done intraoperatively, 24 hours and 7 days using VAS. Wound healing and recurrence of pigmentation was assessed at one month and three months.
Results: No significant difference was noted between the two groups for pain assessment at 7 days with P > 0.001. Both electrosurgery and laser group showed significant differences between intraoperative time period to 24 hours and 24 hours to 7 days at P < 0.001 for pain.
Conclusion: Esthetic demands necessitate cosmetic gingival depigmentation procedure. Laser diode photoablation proves to be an effective and reliable technique in achieving the same. Copyright:

INTRODUCTION

A confident and an attractive smile is determined by the health and appearance of gingiva.[1] The color of gingiva is usually described as coral pink. Gingival pigmentation presents as a deep purplish, diffuse discoloration or as irregularly shaped brown and black patches, striae or strands.[2] The primary pigments which contributes to normal gingival color are melanin, carotene, decreased hemoglobin and oxyhemoglobin. Of this, melanin has maximum occurrence.[3]

Gingival depigmentation is a periodontal surgical procedure wherein gingival hyperpigmentation is removed employing different techniques. Enhanced esthetics is the primary indication for demand of depigmentation procedure.[4] Literature evidence shows various methods of depigmentation, such as scalpel surgery, cryosurgery, electrosurgery, chemical methods, and lasers of different kinds such as neodymium, aluminum-yttrium-garnet (Nd-YAG) lasers, diode lasers, erbium-YAG lasers, and carbon dioxide (CO2).[56]

The diode laser utilizes gallium (Ga), arsenide (Ar), Aluminum (Al), and Indium (In) in combination so as to convert electrical energy to light energy. This solid semiconductor possesses wavelength and energy that particularly targets soft tissues. Because of its tendency toward hemoglobin and melanin, its efficiency and specificity in targeting deeper soft tissue is better than other techniques.[7]

The present study was undertaken to answer the research question, “Is there a difference between electrosurgery and diode laser in reducing gingival pigmentation considering outcomes of pain, wound healing response, and repigmentation?”

MATERIALS AND METHODS

A randomized, double blind, parallel design clinical trial was done on 40 patients to evaluate the objective mentioned. Informed consent of all participants was obtained after explaining the risks and benefits of the study. Institutional ethical clearance was taken. The study was carried out in the Department of Periodontics, Sardar Patel Dental College and Hospital.

Study subjects were randomly allocated into two groups; Group 1 was treated with electrosurgery and Group 2 was treated with diode laser, only after fulfilling the eligibility criteria. Patients with moderate to severe gingival pigmentation in the bimaxillary anterior region, based on the criteria of Gupta et al[8] and presenting with optimal oral hygiene were included.

Parameters assessed

Pain

Visual analogue pain scale was used for evaluating pain response, which consists of a horizontal line of 10 cm length (100 mm), marked as “no pain” at the extreme left, and “unbearable pain” at the extreme right. Depending on the severity of pain, patients were asked to mark them. VAS score was recorded as 0 = No pain and 10 = Severe pain, based on distance between two extremes of left and right, in centimeters.

Healing response

Healing was checked by using the Wound Healing Index scores of Huang et al.[9] (2005), 24 hours postoperatively and after a week. Gingival swelling, redness, pus, patient pain, and flap dehiscence and suppuration are all taken into account while calculating the index.

Melanin pigment re-appearance

Relapse of the condition was measured after one month and three months as per the criteria of Hanioka et al.[10] (2005), which has a coding of 0 to 1.

The overall response of the patient was obtained by a patient evaluation form incorporating criteria of pain, cosmetic changes, and expectations met.

RESULTS

All the patients in both groups completed the study with no loss to follow up. Overall, the tolerance by patients to both procedures was good.

Within the group, comparison for electrosurgery group showed statistically significant difference from 24 hours and intraoperative time period to seven days, with VAS scores decreasing to 0.7000 ± 0.7654 from 3.100 ± 1.6189 (24 hours), and 2.700 ± 1.3416 (IP) [Table 1]. Pain reduction was significantly appreciated seven days later. In the laser group comparison for pain scores, pain levels exaggerated from IP to 24-hour time interval, which was significant. Pain reduced significantly in the 7th day follow up [Table 2]. Intergroup comparison for VAS scores at seven days presented no difference between electrosurgery and laser group [Table 3]. The healing score showed a significant difference between the groups, with uneventful healing reported in all cases of laser group in one month as against 15 cases in the electrosurgical group [Table 4]. Melanin pigment reappeared in three cases of Group II as against four in Group I, which was non-significant [Table 5]. Overall, patients treated with laser showed better results for the variables of pain and healing across all time periods [Figures 1-6].

Table 1

VAS score comparison in electrosurgery (Group 1) at various time intervals

Time intervals	Mean+SD	t	P
VAS Intraoperative	2.7000±1.3416	1.165	0.258 (NS)
VAS 24 h	3.1000±1.6189
VAS 24 hours	3.1000±1.6189	9.037	<0.001**
VAS 7 days	0.7000±0.7654
VAS Intraoperative	2.7000±1.3416	7.646	<0.001**
VAS 7 days	0.7000±0.7654

NS=Nothing Significant; *Significant; **Highly Significant

Table 2

VAS score comparison in diode laser (Group 2) at various time intervals

Time intervals	Mean±SD	t	P
VAS Intraoperative	0.7000±0.7327	5.604	<0.001**
VAS 24 hours	1.6000±0.8207
VAS 24 hours	1.6000±0.8207	7.804	<0.001**
VAS 7 days	0.3500±0.4893
VAS Intraoperative	0.7000±0.7327	2.101	0.049*
VAS 7 days	0.3500±0.4893

NS=Nothing Significant; *Significant; **Highly Significant

Table 3

Intergroup comparison of VAS scores between electrosurgery and diode laser groups across time intervals

Groups versus time intervals	Mean±SD	Mean rank	P
VAS Intraoperative			<0.001**
Group 1	2.7000±1.3416	28.65
Group 2	0.7000±0.7327	12.35
VAS 24 h			<0.001**
Group 1	3.1000±1.6189	26.90
Group 2	1.6000±0.8207	14.10
VAS 7 days			0.122 (NS)
Group 1	0.7000±0.7654	23.03
Group 2	0.3500±0.4893	17.93

NS=Nothing Significant; *Significant; **Highly Significant

Table 4

Intergroup comparison of wound healing index scores after 24 hrs and after 1 week between electrosurgery and diode laser groups

Scores	24 h		1 week
	Group - I	Group - II	Group - I	Group - II
1 - Patient pain or flap dehiscence are not present throughout the healing process of this incision. There is no gingival edema or erythema	15	20	20	20
2 - Patient pain or flap dehiscence are possible side effects of an uneventful wound healing process. No suppuration	5	0	0	0
3 - There is substantial gingival edema, severe erythema of the gingival tissue and patient pain, as well as any suppuration of the flap	0	0	0	0
Total	n=20	n=20	n=20	n=20

Chi-squared test=5.714; P=0.024*

Table 5

Intergroup comparison for re-appearance of melanin pigments after 1 month and 3 months

Melanin Pigmentation Index Score	Group - I (n=20)		Group - II (n=20)
	1 month	3 months	1 month	3 months
0 - No Pigmentation	18	16	19	17
1 - Non-extensive solitary units of pigmentation in papillary gingiva with no expansion between them	02	04	01	03
2 - Formation of continuous ribbon extending from neighbouring solitary units	00	00	00	00
Total	20	20	20	20

Chi-squared test=0.173; P=0.500 (NS)

Figure 1

Preoperative gingival pigmentation – Electrosurgical group

Figure 6

Post-Op view after 3 months

Laser-assisted depigmentation being done in maxillary arch using Picasso, AMD LASERS, USA TM

Electrosurgery-assisted depigmentation being done in mandibular arch using PerFect TCS II, Coltene, Switzerland TM

Post -Op view after 1 week

Post-Op view after 1 month

DISCUSSION

It is the accumulation of melanin by melanocytes in the basal epithelial layer of the oral mucosa that results in the pigmentation of the skin. Mechanical, chemical, and physical stimulation are all factors that contribute to the severity of a condition, even if it is predisposed genetically. Research participants who had melanin pigmentation that could be treated with electrosurgery and diode laser were included in this study.

An electrical shock causes the melanotic cells in the operated region to disintegrate molecularly, validating Oringer's exploding cell theory.[11] To accomplish depigmentation, the sides and tip of the electrode are used, resulting in injury to the surrounding tissues.[12] A major drawback of electrosurgery is its inability to control necrotic depth in treated tissue due to the high temperature.[13] Thus, prolonged and repeated exposure to electrosurgical energy results in tissue damage of an undesirable kind.

Using a visual analogue scale (VAS), we were able to measure the intensity of discomfort. Vagus nerve stimulation (VNS) was also employed in investigations by Chandna S and colleagues[14] in 2015, as was also by Harpreet Singh Grover and colleagues in 2014. In addition to being responsive to intervention results, VAS ratings may be statistically analyzed.[14] Because protein coagulum collects on wound surfaces and serves as biological wound dressing, it reduces pain perception in the laser group. Measurements were taken at the same time of day and in noise-free and ideal temperature conditions to provide an objective assessment of pain perception, which might be affected by environmental variables.

Both intraoperative and one-week follow-up of pain ratings demonstrated statistically significant differences between the groups on the 7th day. This is similar to the results of Chandna et al.,[14] who studied the effects of electrosurgery and laser treatment on ten patients in each group. Kaarthikeyan et al.[15] also found that 970 nm diode laser treatment resulted in lower pain ratings than the knife approach. Patients who had a laser treatment reported decreased discomfort, either because of Na K pump disruption in cell membranes, which resulted in loss of impulse conduction or because of protein coagulum mesh.[16]

There was a statistically insignificant difference in the number of recurrences of melanin pigmentation between the laser and electrosurgical groups. Grover et al.[1] found similar results, with 4 out of 20 laser patients and 7 out of 20 scalpel patients demonstrating repigmentation on the 30th day of follow up. The specific process of recurrence or the pigmentation of melanin is unknown. In the investigation of Ginwall et al.,[17] 50% of the abrasion method cases and 19% of the surgical bur-oriented gingival depigmentation were found.

The benefit of using a diode laser was the shorter operating time and reduced postoperative discomfort and agony.[18] To further understand the pathophysiology of repigmentation, more research is needed that include longer follow-up periods and histologic evaluations.

CONCLUSION

Both techniques were equally effective at the end of study period for pain and recurrence of melanin pigmentation, though laser technique offered a slight edge over the electrosurgical method. The type of technique chosen must be based on patient factors, such as degree of pigmentation, acceptability, compliance, and affordability.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.