Management of Gingival Hyperpigmentation using Diode Laser and Co2 Laser Therapy: A Comparative study

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MANAGEMENT OF GINGIVAL HYPERPIGMENTATION

USING DIODE LASER AND CO2 LASER THERAPY:

A COMPARATIVE STUDY

Dissertation submitted to

THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY

In partial fulfillment for the Degree of

MASTER OF DENTAL SURGERY

BRANCH III

ORAL AND MAXILLOFACIAL SURGERY

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ABSTRACT

DISSERTATION TITLE: Management of Gingival hyperpigmentation using Diode laser and CO2 laser therapy: A comparative study.

BACKROUND:

A smile expresses a feeling of joy, success, sensuality, affection, and courtesy and can

reflect self-confidence and kindness. The aesthetic needs of the patients are increasing day by

day. Each and every patient wants a beautiful smile.The pigmentation of the gingiva, when it is

not related to the skin complexion, is a dampening factor in an otherwise acceptable smile

window. In recent years, the use of laser photoablation has been recognized as one of the most

effective, pleasant, and reliable techniques for treatment of gingival hyperpigmentation.

Different lasers have been used for gingival depigmentation, including carbon dioxide (CO2)

(10,600 nm), diode (820 nm), neodymium-doped:yttrium, aluminium, and garnet (Nd:YAG)

(1,064 nm), erbium (Er-doped:YAG) (2,940 nm), and erbium- and chromium-doped:yttrium,

scandium, gallium, garnet (Er,Cr:YSGG) (2,780 nm) lasers. This study compares the efficiency

of carbon dioxide (CO2) and diode laser techniques to change the colour of the gingiva in the

treatment of gingival hyperpigmentation by assessing the colour of the gingiva, gingival

bleeding, operator’s difficulty, post operative wound healing, pain and esthetic perception by the

patient at 1 week,2 week,3 week and 4 week post-operatively.

MATERIALS AND METHODS:

This double-blinded study was conducted at Department of oral and maxillofacial

surgery, Rajas dental college and hospital, Tirunelveli from February 2013 to November 2015.

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TheRajas dental college.The patient was blinded about the type of laser used for depigmentation

of his/her gingiva. Gingival depigmentation was done from canine to canine in the upper anterior

region.A total of 20 anterior segments were treated: 10 randomly to Carbon dioxide & Diode

Laser group using Flip coin method. Pre-operative photographs & Post operative radiographs

were obtained with a digital camera with standardized settings for grey, white, black and a cm

scale with standard lighting and backdrop. Macroscopic distribution and colour of the

pigmentation of all surfaces were recorded in detail. A single surgeon performed the procedure

in each segment using diode or CO2 laser as allocated by the co-investigator. The primary

investigator who was blinded about the allocation of segment evaluated the primary or secondary

parameters like colour of the gingival, bleeding, difficulties of the operator, pain perception of

patient and post-operative wound healing. The parameters were evaluated intra- operatively and

post-operatively till 4th week of follow-up.

DATA ANALYSIS:

The collected patient data were tabulated and statistical analysis were performed.

Microsoft Excel 2010 software to derive the mean and standard deviation and SPSS software

version 21 was used for statistical analysis. Charts and graphic representations were obtained

with the results. Descriptive statistics done by Measures of central tendency E.g. Mean and

Measures of Dispersion E.g. Standard deviation was calculated for all the parameters. Inferential

Statistics was done by unpaired student ‘t’ test to compare the mean difference between the two

groups for difference in the colour of the gingival, bleeding, difficulties of the operator, pain

perception of patient and post-operative wound healing.P value of 5% was considered

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RESULTS AND STATISTICS:

A total of 10 patients were selected for treatment of gingival hyperpigmentation. Out of

10 patients in the study group 6 were males and 4 were females. Pre-operatively,in both the study

group, the colour of the gingiva was heavy. The results of this study shows that the degree of

pigmentationat the end of 4thweek wasless in diode group with 20% of the patient showing no pigmentation compared to CO2group (10%). Unpaired student‘t’ test was done to assess the

difference in colour of gingiva pre and post-operatively.There was slight statistical significance

between the two groups in the colour of the gingival (p value=0.047*).Regarding difficulty of the

operator and pain and wound healing, there was no statistical significant difference between the

diode and CO2group (p value=1,000NS).In case of bleeding, there was marginally significant

difference between the diode and CO2group (p value=0.0632+) in the immediate post-operative

period. With regards to esthetic perception by the patient, there was marginally significant

difference between the diode and CO2group (p value=0.0632+) at the end of 4th week. Regarding

the aesthetic consideration diode laser group scored more satisfaction than CO2 laser study

group.

SUMMARY AND CONCLUSION:

Growing aesthetic need requires the removal of hyperpigmented areas to create pleasant

and confident smile which altogether alter personality of an individual. From our study we come

to the conclusion that on comparing both the group diode laser study group had better outcome

than CO2 laser study group.

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ABBREVATIONS

Bd

-

Bleeding

CO

2

-

Carbon dioxide

COG

-

Colour of gingival

DO

-

Difficulty of the operator

Imm-post-op -

Immediate post operatively

Intra-op

-

Intra operatively

OE

-

Overall esthetics

Post-op

-

Post operatively

PP

-

Pain perception

Pre-op

-

Preoperatively

VAS

-

Visual analog scale

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Esthetic dentistry targeted at designing the perfect smile is delivered only by harmonious blend of the soft and hard tissues of the oral cavity. Very often deft clinical efforts at managing esthetic discrepancies of teeth are hampered by not so satisfactory soft tissue profiles. One of the deciding factors of the soft tissue profile is the colour of the gingiva. The color of the gingiva varies among different individuals, and depends on the vascular supply of the gingiva, epithelial thickness, degree of keratinisation of the epithelium and the presence of pigmented cells38.

Oral pigmentation is the discoloration of the mucosa or gingiva. It can be either due to physiological or pathological conditions. Gingiva is the most common site of pigmentation in the oral cavity. Gingival hyperpigmentation is seen as a genetic variation in some populations independent of their age and sex and termed as physiological or racial gingival pigmentation. Melanosis of the gingiva is frequently present in dark-skinned ethnic groups as well as in different medical conditions. Although pigmentation of the gingiva is a completely benign condition it is an esthetic problem in many individuals.

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The colour of the attached and marginal gingiva is generally described as coral pink29. The pigmentation of the gingiva, when it is not related to the skin complexion, is a dampening factor in an otherwise acceptable smile window43 Although melanin pigmentation of the gingiva is completely benign and does not present a medical problem, complaints of black gums are common particularly in patients who have a very high smile line (gummy smile)45, 10

Causes for Pathologic Oral Pigmentation10, 56

 Endogenous Factors 1. Diseases that increase melanin pigmentation:

Addison’s disease, Peutz-Jeghers syndrome, Albright’s syndrome, Von Reckling Hausen disease.

2. Bile pigments can stain skin and mucous membranes

3. The deposition of iron in hemochromatosis that can stain oral mucous membranes

4. Polycythemia, Cyanotic conditions

 Exogenous factors

1. Atmospheric irritants(coal and metal dust) Colouring agents in food or lozenges

2. Metallic pigmentation: heavy metals (bismuth, lead, arsenic mercury and silver)

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4. Amalgam tattoo

5. Anti-malarial drugs

Melanin, carotene, reduced hemoglobin and oxy hemoglobin are main pigments which contribute to the normal color of gingiva. Gingival hyperpigmentation is a condition in which there will be an increased pigmentation beyond the normally expected degree of the oral mucosa6. Gingival pigmentation may appear as early as 3 hours after birth.55 Gingival pigmentation is considered to be multifactorial.6.The most common cause for gingival hyperpigmentation is due to excessive melanin deposition by melanocytes, which in turn depends on the activity of enzyme tyrosinase. Melanin pigmentation of the gingiva is completely benign and does not presents a medical problem49

Pathogenesis of hyperpigmentation

Melanin is derived from the Greek word ‘‘melas,’’ which means black25. It is an endogenous pigment produced by the melanocytes which are cells of neural crest origin present in the basal and suprabasal layers of the epithelium3, 44

Melanocytes are round nucleus with a double nuclear membrane, and a clear cytoplasm, lacking desmosomes or attachment plates. It contains few intracellular

filaments, but an abundance of mitochondria which sometimes fill the cytoplasm. Biochemically, polypeptides are synthesized in ribonucleoprotein granules,

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capable of melanogenesis. Tyrosinase activity is present in premelanosomes and melanosomes, but absent in melanin granules.55

Active melanocytes synthesize tyrosinase enzyme, which accumulates in the vesicles of the Golgi apparatus, leading to formation of premelanosomes. Tyrosinase enzyme leads to oxidation of tyrosine via a number of intermediate products, including dihydroxyphenylalanine (DOPA), resulting in the formation of a dense pigment melanin, which forms homogeneous, opaque melanosomes. Premelanosomes are transferred by melanocytes to the adjacent keratinocytes by cytocrine ability. This process is known as inoculation, where in keratinocytes play an active phagocytic role. This structural and functional relationship gives rise to the concept of the epithelial–melanin unit. Individuals, regardless of race, have approximately the same number of melanocytes in any given region. A ratio of 1:15 (Melanocyte / Basal keratinocyte) has been found in the human gingival epithelium.55

Epidemiology of hyperpigmentation

Gingival hyperpigmentation is seen as a genetic trait in some population and is more appropriately termed as physiological or racial gingival pigmentation. Physiologic pigmentation is probably genetically determined, but as Dummett suggested, the degree of pigmentation is partially related to mechanical, chemical and physical stimulation. There were no significant difference in oral pigmentation between males and females.56 Fair-skinned individuals are very likely to have non-pigmented gingiva, but in darker Fair-skinned persons, the chance of having pigmented gingiva is extremely high.

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different areas of the same mouth.56 The distribution of oral pigmentation in black individuals is as follows: gingiva = 60%; hard palate = 61%; mucous membrane = 22%; and tongue = 15%. The highest rate of gingival pigmentation has been observed in the area of incisors. The rate decreases considerably in the posterior region.3

The prevalence of melanin in different population has been reported to vary between 0% to 89% with regard to ethnic factors and smoking habit. Complaints of 'black gums' are common among the patients having a very high smile line (gummy smile) and hyperpigmented gingival tissue often forces patients to seek cosmetic treatment. Although melanin pigmentation of the gingiva is completely benign, cosmetic concerns are common, particularly in patients having a very high smile line (gummy smile).

Oral pigmentation index (DOPI):35

This index of oral pigmentation is the commonly used index due to its simplicity and ease of use.

The scores are as follows:

– 0= No Clinical Pigmentation (Pink tissue)

– 1= Mild (Light brown tissue)

– 2= Moderate (Brown tissue)

– 3= Heavy (Deep brown or Black tissue) Gingival pigmentation index: 35

• Score 0: Absence of pigmentation

• Score 1: Spots of brown to black color or pigments.

• Score 2: Brown to black patches but not diffuse pigmentation

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Methods of depigmentation

In 1951 an attempt was made to burn out the pigmented gingiva by using phenol and alcohol. But the attempt was futile in completely eliminating the pigments and the gingival repigmentation and the depth was difficult to control1

Different Technique Employed56

 Methods aimed at removing the pigment layer

 . Surgical methods of depigmentation

 Scalpel surgical technique

a. Slicing, or partial thickness flap technique b. Bone denudation

c. Abrasion d. Scraping e. Gingivectomy

 Cryosurgery

 Electrosurgery

 Laser surgery like Nd:YAG, Er:YAG, CO2 lasers

 Chemical method of depigmentation using caustic chemicals. Eg. 90% phenol

 Methods aimed at masking the pigmented gingiva with grafts from less pigmented areas.

 Free gingival grafts (FGG)

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Of all these techniques the laser have proved to be very effective in the management of gingival hyperpigmentation and it provides less morbidity.

Lasers in dentistry

LASER- Light Amplification by Stimulated Emission of Radiation. It’s an Electromagnetic wave with Monocromatic – Coherent - Collimated6

Lasers were first introduced in 1960 by Maiman and were brought into general practice by Dr William and Terry Myers.31 Lasers have been used in dentistry since the beginning of the 1980s.23 Over the last decade there has been a progressive increase in research concerning application of lasers to various clinical problems and a refinement of the concepts of laser/ soft tissue interactions.2 In recent years, the use of laser photoablation has been recognized as one of the most effective, pleasant, and reliable techniques for this purpose23

Laser production needs

o A source of Energy ( Electrical or another light source)

o Laser medium ( Solid, liquid, gaseous)

Each laser has a particular wavelength. When laser is directed at a tissue component called Chromosherepes each tissue has inherent absorption capacity for a particular wavelength. Different lasers have been used for gingival depigmentation, including carbon dioxide (CO2) (10,600 nm), diode (820 nm), neodymium-doped:yttrium, aluminium, and

garnet (Nd:YAG) (1,064 nm), erbium (Er)-doped:YAG (2,940 nm), and erbium- and

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CO2 laser

CO2 laser introduced in 1965 by Polanyi & associates, CO2 laser wavelength is

absorbed by water based tissues resulting in vaporization of intra and extra cellular fluid & disintegration of cells. Collateral thermal damage is less.

In a Carbon Dioxide Laser, an electrical current is passed through a mixture of several gases, including Carbon Dioxide. The current oscillates very quickly from positive to negative, and excites the Carbon Dioxide molecules, causing them to shed the extra energy as a photon of light. This light, which is infrared light, can then be focused into a beam and used for multiple applications. High energy Carbon Dioxide Lasers are often used in manufacturing and industrial applications and low energy lasers are used for surgical procedures

Carbon Dioxide Lasers work very well for soft tissue surgical procedures because the specific type (wavelength) of the infrared light produced by the laser is absorbed very well by the water in the tissue (soft tissue is mostly water). During surgery, the target tissue is vaporized very efficiently by the laser beam. The energy absorption of the tissue is so efficient that the energy only penetrates about 0.1 mm into the adjacent tissue, regardless of the depth of the cut. CO2 laser causes minimal damage to the periosteum and underlying

bone and it has unique characteristics of being able to remove a thin layer of epithelium cleanly.9 CO2 laser can damage tooth surface and the delivery system is very cumbersome.

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Diode Laser

Diode laser was introduced in 1995. The diode laser is a solid-state semiconductor laser that typically uses a combination of Gallium (Ga), Arsenide (Ar), and other elements, such as Aluminum (Al) and Indium (In), to change electrical energy into light energy.6 The semiconductor diode laser is emitted in continuous-wave or gated-pulsed modes, and is usually operated in a contact method using a flexible fibre optic delivery system22, 6

The 810-nm diode laser has energy and wavelength characteristics that specially target the soft tissues. It has an affinity for hemoglobin and melanin, therefore it is more efficient and better equipped to address deeper soft tissue problems.20

Diode lasers usage is similar to electrocauterization. Semi conductor diode laser has been used for gingivectomy, frenectomy, incisional and excisional biopsy, soft tissue tuberosity reduction, operculectomy, coagulation of donor site, and exposure of soft tissue covering osseointegrated implants14 and for numerous “fixed” soft tissue procedures including gingival hyperplasia, crown lengthening and hyperpigmentation.20

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Advantage of laser

The advantages of diode lasers are the smaller size of the units as well as the financial costs.6 The diode laser causes minimal damage to the periosteum and bone under the gingiva being treated. It has the unique property of being able to remove a thin layer of epithelium cleanly.22

There are many advantages of laser over surgical procedure. These include:

1. Dry and bloodless surgery,

2. Instant sterilization of surgical site,

3. Reduced bacteremia,

4. Reduced mechanical trauma,

5. Minimal post operative scaring and swelling,

6. Minimal post-operative pain. 11, 6

Pain reduction after using lasers may be due to the protein coagulum formed on the wound surface that seals off sensory nerve endings and it also acts as a biologic dressing. The rapid wound healing after using lasers may be related to the photobiomodulation (PBM). PBM accelerates lymphatic and blood flow resulting in reduction in toxins and contributes to a larger expression of collagen and elastic fibers during the early phases of the wound-healing process. This helps to reduce pain, enhance repair, and induce regeneration thus promoting faster healing and return to the normal.11

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needs expensive and sophisticated equipment that is not available commonly at all places and makes the treatment very expensive.54 The advantages of diode lasers are the smaller size of the units as well as the lower financial costs. Diode laser did not produce any deleterious effect on the root surface54, 22

Laser safety

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AIM OF STUDY

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AIM OF STUDY:

TO COMPARE THE CLINICAL EFFICIENCY OF CO2 AND DIODE

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OBJECTIVE OF STUDY

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OBJECTIVES:

PRIMARY:

To compare the efficiency of carbon dioxide (CO2) and diode laser techniques to change

the colour of the gingiva in the treatment of gingival hyperpigmentation.

SECONDARY:

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Hans-Henning Horch et al (23) (1986) gained experience in the treatment of patients

with oral dysplastic precancerous lesions with CO2 laser. Besides 7 lichens planus, 50

leukoplakias of all grades of dysplasia, and carcinoma in situ and one lentigo maligna were

removed superficially with a defocused laser. Within the average follow-up period of 37 months,

22% local recurrences were observed. In comparison with conservative drug therapy,

conventional surgical procedures, and cryosurgical therapy, the CO2 laser treatment of

multicentric premalignant diseases of the oral mucosa 'can be recommended as an alternative

therapy.

Phimon Atsawasuwan et al (34) (2000) presented a case report of four cases that used

Nd:YAG laser for gingival depigmentation. The Nd: YAG laser was set at 6 watts,60 millijoules

per pulse, and 100 pulses per second. The procedure was performed with contact mode in all

pigmented areas by using a handpiece with a 320 micrometer diameter fibre optic. Three to four

weeks after the procedure the hyperpigmented gingiva appeared healthy, pink, and firm. No

recurrence of hyperpigmentation was found in 11 to 13 months of follow-up.

Mattias Kreisler et al (32) (2001) evaluated the effects of diode laser treatment of root

surface specimens on the attachment of periodontal ligament cells in vitro. He observed that

there was no significant positive effect on the new attachment of PDL cells on the tooth

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Atif Kazmi et al (7) (2002) conducted a retrospective study examined hair removal using

Lightsheer Diode Laser System among 1000 women, and demonstrated that the Light Sheer

Diode Laser System provides both safe and effective removal of unwanted hair in patients

Esen E et al (18) (2004) evaluated the use of the flexible fiber CO2 surgical laser for

treating Gingival Melanin Pigmentation. Not only was the ablation of the pigmented gingiva

achieved without any bleeding, there was also no charring or carbonization during any of the

procedures. None of the patients required repetition in the early postoperative period, and healing

was completed in just 2 weeks, without any scar formation. There were no infections or

significant postoperative complications. The study concluded that using the CO2 laser in Super

Pulse mode is an effective and safe method for the elimination of Gingival Melanin

Pigmentation.

A. Chandu et al (12) (2004) presented a clinical paper regarding the use of CO2 laser in

the treatment of oral white patches. Forty-three patients with 73 primary oral leukoplakia were

assessed for outcome and factors affecting survival. The mean observation time was 47.2 _ 28.2

months (range 2–102 months). Disease-free survival was 55.4% at 3 years that dropped to 33.9%

after 5 years. The malignant transformation rate was 7.3%.The results demonstrated that there is

no significant prognostic factors were found on univariate analysis but alcohol consumption (P =

0.034) and previous malignancy (P = 0.018) were found to be significant prognostic indicators

using multivariate analysis. Continuation to smoke approached significance (P = 0.061)

G.Berk et al (9) (2005) presented two cases regarding gingival depigmentation using an

Er,Cr:YSGG laser, and a short follow-up period(6 months) for repigmentation results. There was

no intra-operative or post operative pain or discomfort. After 24hours the laser gingiva was

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The ablated wound healed almost completely in 1 week. The results pointed out that YSGG

laser is a good and safe choice for removal of pigmented gingiva without local anesthesia. The

postoperative period is comfortable for the patient and healing is fast and good. No

repigmentation occurred in either patient after 6 months.

Carlo Maiorana et al( 11) (2006) used superpulsed diode laser for different surgical

procedures like to uncover impacted teeth, remove epulis, and treat intraoral hemangioma. The

use of a superpulsed diode laser allowed the surgeon to operate using high energy and very short

pulse duration.This allow the best control of insicion depth and reduced the thermal damage to

the target tissue.

Sameer A. Mokeem et al (41) ( 2006) reported three cases of gingival depigmentation

using surgical ablation. He observed that the technique was relatively simple and versatile and

requires minimum time and effort. If repigmentation occurs, the procedure can be done

repeatedly in the same area without limitation or causing any permanent damage. After eighteen

months follow up, none of the cases showed any recurrence of the pigmentation.

Daniel Simo˜es et al (14) ( 2007) conducted a study that reported removal of gingival

melanin pigmentation using an Er:YAG laser in a short-term clinical observation. His

observations were Er:YAG laser effectively ablated the epithelial tissue containing melanin

pigmentation. At 1 week, gingiva showed fast epithelization with a healthy appearance in all

cases. At 2 weeks, gingiva showed satisfactory healing with significant improvement in color

and recovery of the tissue thickness. At 1 month, complete healing was observed; after the

3-month evaluation, no gingival deformity or recession was observed. However, there was a slight

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Manal M. Azzeh et al (29) in 2007 conducted a study in which sixty patients were

included.They used Erbium-Doped: Yttrium Aluminium and Garnet laser for treatment of

gingival depigmentation for esthetic purpose. In all patients, no discomfort, pain, or bleeding

complications were found intraoperatively or 4 days postoperatively. Ablated wounds healed

almost completely within 4 days. No recurrence of gingival hyperpigmentation was found during

the follow-up periods. They concluded that that the depigmentation of melanin hyperpigmented

gingiva by the Er:YAG laser is a reliable and satisfactory procedure.

Supaporn Suthprasertporn et al(48) (2007) presented a case report of two cases in the

treatment of gingival melanin hyperpigmentation by Er,Cr:YSGG laser device which was set at

1.0-1.75 watt,7% water and 11% air for gingival ablation, and then 0.5 watt,0%water and 11%

air for biological bandage. He observed that removal of melanin pigment was seen immediately

after treatment. Healing was good within a week. No post operative complication such as

infection, pain or bleeding was encountered. The final outcome was satisfactory for all patients.

Slight repigmentation was found in one patient in the eleventh month of observation.

Sushma Lagdive et al(49) (2009) describes two simple and effective surgical

depigmentation techniques scalpel blade surgery and semiconductor diode laser surgery -for

gingival depigmentation. Better results were achieved with semiconductor diode laser than

conventional scalpel blade surgery.

Ameet mani et al(2) (2009) presented a case report that described three different surgical

depigmentation techniques scalpel blade surgery, abrasion with diamond bur, and semiconductor

diode laser for gingival depigmentation. Better results were achieved with semiconductor diode

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Hyuk-Jin Ko et al(24) ( 2010) evaluated the clinical effectiveness of and patient’s

satisfaction with treatment of gingival melanin hyperpigmentation with a Nd:YAG laser and a

high speed rotary instrument. In all cases, both anterior gingival areas were depigmented with

satisfaction and the patients did not complain of severe pain or discomfort. At the 1st week of

healing, the gingiva showed moderate to fast epithelization. Two weeks after the procedure,

clinically, the gingiva showed almost complete healing. Four weeks after the procedure, there

was significant improvement in gingival melanin hyperpigmentation. He concluded that the

Nd:YAG laser and the high speed rotary instruments seem to be effective for the esthetic

treatment of gingival melanin hyperpigmentation.

A pilot study conducted by Valerie G.A.Suter et al(51) (2010) evaluated the

histopathological characteristics and suitability of CO2 and diode laser for performing excisional

biopsies of similar lesions of the oral mucosa. His observations were the thermal damage zone of

the excised specimens created by the CO2 laser was significantly less pronounced than with the

diode laser. He also observed that the CO2 laser was more appropriate than the diode laser for

intraoral excision of premalignant or malignant lesion where the margins of the removed

specimens must be histopathologically evaluated.

Dosumu Oluwole O et al(17) (2010) determined the predominant gingival tissue color in

Nigerian environment. They assessed the association of gingival tissue color with gender and

facial skin color. They found that there is no significant association between gingival color and

gender. The study supported that there is strong relationship exist between facial skin color and

gingival tissue pigmentation.

Kumara Ajeya E G et al(27) ( 2011) presented a case report in which he compared the

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healing responses and patient satisfaction. Maxillary anterior region was the area of concern for

the patient, where at the right side scalpel technique and at the left side. Both the treatment

modalities showed comparative results in terms of patient acceptance. Scalpel depigmentation

resulted in uneventful healing of the treated site. Laser depigmentation resulted in absolute

bloodless field which healed uneventfully. Patient discomfort was more in laser treated areas

during the initial healing period.

Goksel Simsek Kaya et al(20) ( 2011) compared the use of diode and Er:YAG laser in

treating gingival melanin pigmentation in terms of gingival depigmentation local anaesthesia

requirements, post operative pain/discomfort, depigmentation effectiveness, and total treatment

duration. Procedures were carried out without the need for any topical or local anesthetic, and no

unpleasant events occurred during the actual procedure or the healing period. The total length of

treatment was significantly shorter with the diode laser than with the Er:YAG laser. No melanin

recurrence was detected during any follow-up session.

Geeti Gupta et al(19) ( 2011) presented a case report that described simple and effective

depigmentation technique using semiconductor diode laser surgery – for gingival

depigmentation. A 23-year-old male patient complaining of heavily

pigmented gums visited department of Periodontics was considered for study. Healing was good

at 1 month with pink color comparable to nearby non-treated area, resulting in a significant

improvement in aesthetic appearance. No infection or significant postoperative complications

such as pain or bleeding were encountered. Fifteen months follow-up showed no signs of

recurrence of pigmentaion. The method used here produced desired results and above all, the

patient was satisfied with the outcome, which is the ultimate goal of any therapy that is carried

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Maryam Talebi et al(31) (2012) presented a case report regarding the effects of

cryotherapy on physiologic pigmentations of oral mucosa in a 9-year-old boy . Cryotherapy is a

method of tissue destruction by rapid freezing. It is an atraumatic, cost-effective and simple

method for treating oral pig-mentation. This report concluded that the cryotherapy as an

atraumatic, cost-effective and simple method for treating oral pigmentation without recurrent

lesions after 12 months.

Zingade AN et al(56) ( 2012) presented a case report in a 20 years old male patient

reported to the university periodontology clinic with the complaints of darkly pigmented gums

and irregularly placed teeth. It was planned to carry out depigmentaion procedure using different

technique like a scalpel, bur abrasion, cryotherapy and lase for the four different quadrant under

local anesthesia. All the three different techniques followed for depigmentation in this case

provided similar comparable outcomes at 3 months follow-up. There was no evidence of

repigmentation.

Sanjeevini H et al(42) ( 2012) reported two cases of gingival pigmentation treated by

simple surgical technique of de-epithelialization. The procedure adopted was quite simple, cost

effective and less painful with minimal tissue loss and hence can be repeated without

complication keeping in mind the fact that repigmentation is a possibility in most cases. The

above mentioned procedure can also be performed by general dental practitioners to reduce and

lighten the pigmentation and thereby improve the gingival appearance

Sujal Shah et al(47) in (2012) describes two distinct surgical depigmentation procedures:

scalpel blade surgery and semiconductor diode laser for complete removal of gingival

pigmentation, tissue healing following the surgery and fulfillment of patient centered outcomes

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semiconductor laser that combines Gallium (Ga), Arsenide (Ar) and other elements like

aluminum (Al) and Indium (In), converting electric energy into light energy. In this report both

the surgical techniques have shown excellent results, however scalpel blade surgery showed

marginally better results in terms of tissue healing and esthetics.

Walter Duki et al(54) ( 2012) evaluated the effect of a 980-nm diode laser as an adjunct

to scaling and root planing (SRP) treatment. The present results indicated that non-surgical

periodontal therapy using hand instruments and a sonic device alone or in combination with a

diode laser provide significant improvements in clinical parameters like bleeding on probing

(BOP), probing depth (PD), and clinical attachment level (CAL) for both moderate and deep

pockets at 6 and 18 weeks after treatment. In the present study, the use of a 980-nm diode laser

with a power of 2 W as an adjunctive to SRP significantly reduced gingival inflammation during

the observation period, although these results were not superior to the use of SRP alone.

Vishal Singh et al(52) ( 2012) compared and evaluated the gingival depigmentation by

diode laser and cryosurgery using tetrafluoroethane. Both procedures were equally effective in

depigmentation. At the 18-month follow-up, spotted repigmentation was found in one case in

each group. Although there was initial healing discomfort and mild pain with cryosurgery, all the

patients were satisfied with the esthetic outcomes. During the 18-month follow-up, the

depigmentation achieved using both the techniques was found equivalent and satisfactory.

M.Bhanu moorthy et al(10) 2012 reported case series in which she described three

different surgical depigmentation techniques: scalpel surgery, abrasion with rotary abrasive, and

a diode laser. She observed that better results of depigmentation were achieved with diode laser

(38)

REVIEW OF LITERATURE

22

that lasers were an effective and a safe means to removal of hyperpigmentation from the gingiva.

Healing was uneventful and no repigmentation occurred.

F. Agha-Hosseini et al(1) 2012 did a comparative evaluation of low-level laser and CO2

laser therapies for the treatment of oral lichen planus. The clinical trial was conducted with 28

patients. One group received CO2 laser therapy, the other received low-level laser therapy

(LLLT) for 5 sessions every other day. Improvements in size of lesions, in pain and clinical

response scores were achieved in both groups. The present study showed that LLLT displayed

better results than CO2 laser therapy as alternative or additional therapy, but further

investigations in comparison with standard treatment modalities with a prolonged follow-up

period will be necessary to confirm the efficacy of laser therapy in the treatment of OLP.

Gurumoorthy Kaarthikeyan et al (22)( 2012) evaluated intra-operative and

postoperative pain levels by a Visual Analog Scale (VAS) during gingival depigmentation

procedures using scalpel surgery and lasers. He also determined whether the pain responses were

influenced by the age and gender of the patient. This study concludes that laser procedures for

gingival depigmentation produce less pain and discomfort during surgery compared to scalpel

procedures. However there was no difference in the levels of pain 24 hours postoperatively and 1

week postoperatively between the two procedures.

Rashmi Hegde et al (40)(2012) compared the various techniques for gingival

depigmentation like surgical stripping, Erbium-Doped:Yttrium, Aluminium, and Garnet laser;

and carbon dioxide laser. The study also evaluated their effect on histological changes in

melanocyte activity and clinical repigmentation. They concluded that surgical stripping for

gingival depigmentation remained the gold standard. Er:YAG laser and CO2 laser can be

(39)

REVIEW OF LITERATURE

23

A comparative study done by Desai Urmi et al (16)(2013) regarding patient perception on

gingival depigmentation using scalpel and diode laser. VAS score was used for pain perception

after surgery .Pain perception was less when diode laser was used and regarding the esthetic

change, patient expectation and retreatment of the two surgical procedures were at par with one

and another.

A randomized split-mouth clinical trial conducted by Marco Giannelli et al (30) (2013)

compared the clinical efficacy of two different photoablative dental lasers erbium:

yttrium-aluminium–garnet and diode, for the treatment of gingival hyperpigmentation. In the study they

observed that both diode and Er:YAG laser gave excellent results in gingival hyperpigmentation.

Er:YAG laser induced deeper gingival tissue injury than diode laser, as judged by bleeding at

surgery, delayed healing and histopathological analysis. Diode laser caused less postoperative

discomfort and pain.

Santhosh Kumar et al (44) (2013) done a comparative evaluation of the gingival

depigmentation by using Tetrafluoroethane cryosurgery and the gingival abrasion technique – 2

years of follow up. The study group was 10 healthy patients. Tetrafluoroethane was used for the

cryosurgical depigmentation and the gingival abrasion technique used a coarse flame shaped bur.

The statistical analysis which was done after 90th, 180th days and 2 years. The p-value which

was obtained (p<.001) showed the superiority of cryosurgery over the gingival abrasion. During

the follow up period, no side effects were seen for both the techniques and the improved

aesthetics was maintained upto 2 years.

Rajiv saini et al(39) 2013 presented a case report that describes the application of semi

conductor diode laser procedure for gingival depigmentation. In a 25 year old patient the

(40)

REVIEW OF LITERATURE

24

980 nm was selected for the procedure. No postoperative pain, hemorrhage, infection or scarring

occurred in first and subsequent visits. Healing was uneventful. Patient s acceptance of the

procedure was good and results were excellent as perceived by the patient.

Sharmila verma et al(45) 2013 presented a case report in which gingival depigmentation

was done with scraping technique in a 26 old male patient. The healing process was preceded

normally and patient did not report any discomfort. At the end of one month re-epithelialization

was complete and healing was found to be satisfactory. Patient had no complaints of

postoperative pain or sensitivity. At the end of six months the gingiva appeared healthy and no

further repigmentation was seen.

Javier D. Sanz-Moliner et al (26) (2013) compared the tissue response and postoperative

pain after the use of a diode laser (810 nm) (DL) as an adjunct to modified Widman flap (MWF)

surgery to that of MWF alone. Thirteen patients with generalized severe chronic periodontitis

completed the study. Pain scale assessment (PS), pain medication consumption (PM), tissue

edema (TE), and tissue color (TC) were evaluated 1 week after surgery. The results were

statistically significant and he concluded that the use of an 810-nm diode laser provided

additional benefits to MWF surgery in terms of less edema and postoperative pain.

A cross sectional study conducted by Deepa Ponnaiyan et al (15) (2014) correlated the

skin color with gingival pigmentation patterns in South India. She observed that the highest rate

of gingival pigmentation was observed in the area of incisiors. Incidence of pigmentation did not

differ between the sexes.

Basser Ali Abdullah et al (8) (2014) compared the effectiveness of Er Cr YSGG & Diode

laser on de pigmentation of gingival melanin pigmentation & compared their possible

(41)

REVIEW OF LITERATURE

25

simple & accepted by the patients .,both waterlase & diode laser are effective in oral melanin

depigmentation. The use of diode laser is associated with pain &delayed healing compared with

waterlase. According to result of this study we found that waterlase is better than diode laser in

melanin depigmentation.

Amit Bhardwaj et al(3) 2014 undertook a study to to evaluate patient response and

recurrence of pigmentation following gingival depigmentation carried out with a surgical blade

and diode laser. Patients were evaluated for pain (1 day, 1 week), wound healing and melanin

repigmentation (Melanin Pigmentation Index) immediately and at 1 week, 1 month and 3

months, respectively. Comparative pain assessment (P = 0.148) and repigmentation scores (P =

0.288) at various time intervals between the two groups did not show any statistical significance.

Both the procedures did not result in any post-operative complications and the gingiva healed

uneventfully. When compared, both the techniques were found to be equally efficacious.

Shirin Amini Sedeh et al (46)(2014) conducted a study that aimed to compare the

recurrence rate of gingival pigmentation after treatment by liquid nitrogen swap and a cryoprob

in 18 months. A total of 26 patients with physiologic gingival pigmentation were selected. The

anterior sextant was divided into left and right segments; each segment was treated randomly by

swap technique or cryoprob. Standard photos were evaluated with photoshop software (Red,

Green, Blue, Cyan, Magenta, Yellow, Black [RGB, CMYK]) before and at 2 week, 1, 3, 6, 9, 12,

15, 18 months after the treatment. The results were both methods of cryosurgery are appropriate

in treatment of gingival depigmentation because no significant recurrence was observed during

18 months follow-up.

Semih Ozbayrak et al(32) 2014 conducted a study regarding the treatment of melanin

(42)

REVIEW OF LITERATURE

26

procedure well. Clinical keratinization was completed in 3-5 wks after the treatment, and the

treated areas were similar in color to that of the normal mucosa. Clinical repigmentation also did

not occurred in the follow up period of 18 months.

Recent study conducted by Shilpi et al(33) 2014 regarding the surgical esthetic correction

for gingival pigmentation by scalpel technique .Either slicing or scraping of the epithelium was

done using the scalpel. She observed that no complication was encounted and recurrence of

(43)

(44)

MATERIALS & METHODS

27

MATERIALS & METHODS

• The Patients were selected from the outpatient Department of Oral and maxillofacial

surgery, RDC, Kavalkinaru, Tirunelveli.

• A signed informed consent was obtained from all patients willing to participate in this

study.

• A total of 20 anterior segments were treated: 10 randomly to Carbon dioxide & Diode

Laser group by split mouth technique.

• Assignment was performed according to flip-coin method by co-investigator.

• Patients underwent periodontal therapy consisting of oral hygiene instructions and full

mouth oral prophylaxis.

• Gingival depigmentation was planned from canine to canine in the upper anterior region.

• All patients were evaluated by Primary investigator.

• Pre-operative photographs & Post operative radiographs were obtained with a digital

camera with standardized settings for grey, white, black and a cm scale with standard

lighting and backdrop. Macroscopic distribution and colour of the pigmentation of all

surfaces were recorded in detail.

• INCLUSION CRITERIA

• Patient with healthy peridontium

• Patients between 18-40 year of age

• Presence of Melanin pigmentation with score of 3 (DOPI)

• EXCLUSION CRITERIA

• Presence of systemic diseases

(45)

28 • Tobacco users

• Pregnant / Lactating patients

Selection Criteria

• The Cases are selected based on Dummett-Gupta Oral Pigmentation Index (DOPI) 1971

– 0= No Clinical Pigmentation (Pink tissue)

– 1= Mild (Light brown tissue)

– 2= Moderate (Brown tissue)

[image:45.612.128.502.289.625.2]

– 3= Heavy (Deep brown or Black tissue)

(46)

MATERIALS & METHODS

29

Study Methodology-Double blinded

The study was performed as a double blinded study where both the primary investigator

whoevaluated the parameter and the patients were blinded. The co investigator and the primary

investigator were tested for normal colour vision to prevent inter examiner variability. The

co-investigator selected patient with grade 3 pigmentation according to DOPI scale.Then he

randomly allocated each patient’s right or left segment to CO2 or diode group by flip coin

method, with head being diode laser and tail being CO2 laser.All the pre-operative preparations

like photographs were taken care of by the co-investigator. The patient was blinded about the

type of laser used for depigmentation of his/her gingiva.A single surgeon performed the

procedure in each segment using diode or CO2 laser as allocated by the co-investigator. The

primary investigator who was blinded about the allocation of segment evaluated the primary or

secondary parameters like colour of the gingival, bleeding, difficulties of the operator, pain

perception of patient and post-operative wound healing.The parameters were evaluated intra-

operatively and post-operatively till 4th week of follow-up.

Group I: The Equipment used was AMD Diode laser Picasso, USA.Topical anesthetic gel was applied to the surgical field. Special eye glasses were worn by the patient, surgeon and

the staff to comply with the FDA laser safety rules. The properly initiated tip of the diode laser

unit (Picasso, AMD laser technologies, USA; wavelength 810 nm) angled at an external bevel of

45 degrees and at energy settings of 0.5-1.5 watts continuous wave (CW) was used with small

brush like strokes back and forth with gradual progression deeper along the same initial laser

incision to remove the tissue. A 400 μm strippable fiber was used with a power setting of 1.5

watts initially in pulsed wave mode (PW) set at 0.20 ms of pulse duration and 0.10 ms of pulse

(47)

MATERIALS & METHODS

[image:47.612.190.454.117.419.2]

30

Fig 2:

Group II: For CO2 laser Equipment used is NovaPulse LX-20 SP surgical laser

.Preoperative images are taken .The melanin pigmented gingival segment is ablated by CO2 laser

vaporization under local anesthesia. The ablation was performed by a flexible fiber Luxar

NovaPulse LX-20 SP surgical laser, the predecessor of LS-1005. The repeated A5 Super Pulse

mode was applied at 3 watts, 20 Hz, 10 milliseconds, with a 0.8 mm spot size. The remains of

the ablated tissue were removed using sterile gauze dampened with saline. This procedure was

“repeated until the desired depth of tissue removal was achieved.” To protect the adjacent teeth

from the laser beam, either an acrylic template was used to cover the labial surface of the teeth,

(48)

MATERIALS & METHODS

31

In addition, the more precise 0.4 mm laser tip was used at the gingival margins and interdental

papilla; the power setting was also reduced to 3 watts in order to achieve better control and

minimize the risk of tooth damage

Fig 3: Fig 4:

EVALUATION OF THE PRIMARY PARAMETER:

COLOUR ASSESSMENT:

To evaluate the primary parameter the colour of the gingiva, pre-operative photographs

was taken one week before the procedure and post-operative photographs were taken at first,

second, third, fourth week after the procedure of depigmentation.

The photographs were taken using the Canon EOS digital camera, standardized setting

for grey and white, centimeter scale with standard lighting with a manual shutter mode (M). All

[image:48.612.101.498.166.443.2]

(49)

MATERIALS & METHODS

[image:49.612.132.477.115.382.2]

32

Fig 5:

The primary investigator who was blinded about the allocation of segments either to Co2

or diode laser, evaluated the pre-operative and post-operative photographs using DOPI scale

• Dummett-Gupta Oral Pigmentation Index (DOPI):

– 0= No clinical pigmentation (Pink tissue)

– 1=Mild (Light brown tissue)

– 2= moderate ( Brown tissue)

(50)

MATERIALS & METHODS

33

EVALUATION OF THE SECONDARY PARAMETERS:

BLEEDING:

Bleeding was assessed by the primary investigator intra-operatively and immediate

post-operatively

It was evaluated as

A. None B. Slight C. Moderate D. Severe

DIFFICULTY OF THE OPERATOR:

Difficulty of the operator was assessed by the primary investigator intra-operatively using

the Visual Analogue Scale

VAS Score:

(51)

[image:51.612.147.440.110.266.2]

34

Fig 6:

The VAS scale was shown to the surgeon who operated. The surgeon was

asked to mark the difficulty of the procedure. The left extreme end was “Impossible”

procedure. The distance from point from the left end of the scale was recorded

intra-operatively.

PAIN ASSESSMENT:

• Pain was assessed using Visual Analogue Scale

– VAS Score

• 0 = No pain

• 1 = Slight pain (1-3)

• 2 = Moderate pain (3.1-6)

(52)

MATERIALS & METHODS

[image:52.612.161.458.107.265.2]

35

Fig 7:

• The Visual analogue scale was used to evaluate the subjective pain level experienced by

each patient. It consists of Horizontal line 100mm long starting at the left end with the

descriptor “no pain” and ending at the right side with “severe pain”. Patients were asked

to mark the severity of the pain. The distance from point from left end of the scale was

recorded intra-operatively, immediate post-op and first day post-operatively.

WOUND HEALING:

Wound healing was assessed by the primary investigator clinically on the first, second,

third, fourth week post-operatively

It was evaluated by using healing index by Landry et al.

1. Very poor

– Tissue colour: ≥ 50% of gingiva red, response to palpation: bleeding

– Granulation tissue: present

– Incision margin: not epithelialised, with suppuration present

2. Poor

– Tissue colour: ≥ 50% of gingiva red, response to palpation: bleeding

– Granulation tissue: present

(53)

36

3. Good

– Tissue colour: ≥ 25% and < 50% of gingiva red, response to palpation: no bleeding

4. Very good

– Tissue colour: < 25% of gingiva red ,response to palpation: no bleeding

– Granulation tissue: none ,incision margin: no connective tissue exposed

5. Excellent

Tissue colour: all tissues pink, response to palpation: no bleeding

Granulation tissue: none, incision margin: no connective tissue exposed

ASSESSMENT OF PATIENT OPINION ON ESTHETIC CHANGE

Esthetic change was assessed by using Visual Analogue Scale

VAS Score

– 0 = Worst

– 1 = Better (1-3)

– 2 = Beautiful (3.1-6)

[image:53.612.158.458.552.707.2]

– 3 = Most Beautiful (6.1-10)

(54)

37

The VAS was used to rate the esthetic perception as denoted by the patient at the end of 4th week The most extreme left point represent the worst possible esthetic situation whereas the extreme

(55)

(56)

SURGICAL PICTURES & ASSESSEMENTS

38

CASE 1:

PRE OPERATIVE: Fig 9a PRE OPERATIVE: Fig 9b

POST OPERATIVE:

IMMEDIATE POST – OP: Fig 9c 1st DAY: Fig 9d

1st WEEK: Fig 9e 2nd WEEK: Fig 9f

(57)

39

CASE 2:

POST OPERATIVE:

IMMEDIATE POST – OP: Fig 10c 1st DAY: : Fig 10d

1st WEEK: : Fig 10e 2nd WEEK : : Fig 10f

(58)

40

CASE 3:

POST OPERATIVE:

(59)

41

CASE 4:

POST OPERATIVE:

(60)

42

CASE 5:

POST OPERATIVE:

(61)

43

CASE 6:

PRE OPERATIVE:Fig 14a PRE OPERATIVE:Fig 14b

POST OPERATIVE:

IMMEDIATE POST – OP:Fig 14c 1st DAY:Fig 14d

1st WEEK:Fig 14e 2nd WEEK:Fig 14f

(62)

44

CASE 7:

POST OPERATIVE:

(63)

45

CASE 8:

PRE OPERATIVE:Fig 16b PRE OPERATIVE:Fig 16b

POST OPERATIVE:

(64)

46

CASE 9:

POST OPERATIVE:

(65)

47

CASE 10:

POST OPERATIVE:

(66)

(67)

RESULTS & STATISTICS

48

RESULTS AND STATISTICAL ANALYSIS

The collected patient data were tabulated and statistical analysis was performed. Microsoft Excel 2010 software to derive the mean and standard deviation and SPSS software version 21 was used for statistical analysis. Charts and graphic representations were obtained with the results.

RESULTS:

This study included 10 patients with gingival hyperpigmentation. They were aged from 18-23.Mean age of male and female patients were 19.2 yrs and 20.5 yrs respectively. Out of 10 patients in the study group 6 were males and 4 were females (Chart 1). Pre-operatively, in both the study group, the colour of the gingiva was heavy (Chart 2).

The parameters assessed were colour of the gingiva, bleeding, difficulties of the operator, pain perception of patient and post-operative wound healing.

CHART I: SEX WISE DISTRIBUTION

0 2 4 6 8 10 0

6 6

0

4 4 10 10

N o o f p at ie n ts

Sexwise distribution of the study

group

(68)

49

CHART II: COLOUR OF GINGIVA- PRE-OP

ASSESSMENT OF PRIMARY PARAMETER: COLOUR OF THE GINGIVA

The colour of the gingiva was assessed post-operatively for both the CO2 and diode

group at first, second, third and fourth week. In both the study group at the end of 1st week the colour of the gingiva revealed no pigmentation in 2(20%) of the patients and with mild

pigmentation in 8(80%) of the patients (Chart 3). In both the study group at the end of 2nd week the colour of the gingiva revealed no pigmentation in 3(30%) of the patients and with mild pigmentation in 7(70%) of the patients (Chart 4).At the end of 3rd and 4th week, in the diode group, 2(20%) of the patients had no pigmentation, 7(70%) of the patients had mild pigmentation and 1(10%) had moderate pigmentation. In CO2 laser study group, at the end of 3rd and 4th week,

1(10%) patient had no pigmentation. 8(80%) of the patients had mild pigmentation and 1(10%) had moderate pigmentation (Chart 5).

0 2 4 6 8 10 Diode CO2 10 10

0 0

Colour of the gingiva pre-operatively

(69)

50

Regarding the colour of the gingiva both the study group had same results at the end of 1st and 2nd week. But at the end of 3rd week and 4th week the degree of pigmentation was less in diode group than CO2 laser group.

CHART III: COLOUR OF GINGIVA – END OF FIRST WEEK

CHART IV: COLOUR OF GINGIVA – END OF 2ND WEEK

0 2 4 6 8 Diode CO2 N o o f p at ie n ts

Colour of the gingiva at the end of 1st

week

No pigmentation Mild pigmentation 0 2 4 6 8 Diode CO2 3 3

7 7

Colour of the gingiva at the

2nd week

(70)

51

CHART V: COLOUR OF GINGIVA – END OF 3RD WEEK

CHART VI: COLOUR OF GINGIVA – END OF 4TH WEEK

ASSESMENTOF BLEEDING

Bleeding was assessed intra operatively and immediate post-operatively.In both the study group all the patients 10(100%) had moderate bleeding during the time of

0 2 4 6 8

No pigmentation Mild pigmentation Moderate pigmentation 2 7 1 1 8 1 N o o f p at ie n ts

Colour of the gingiva at the end of 3rd

week

Diode CO2 0 2 4 6 8

No pigmentation Mild pigmentation Moderate pigmentation 2 7 1 1 8 1 N o o f p at ie n ts

Colour of the gingiva at the end of 4rd

week

(71)

52

procedure being done (Chart 7). In diode laser study group in the immediate post operative period 2(20%) of the patients had slight bleeding and 8(80%) had moderate bleeding. In CO2

laser study group all the patients 10(100%) had moderate bleeding (Chart 8).

CHART VII: INTRA OP BLEEDING

CHART VIII: IMMEDIATE POST OP BLEEDING

0 2 4 6 8 10 Diode CO2 N o o f p at ie n ts

Intra operative bleeding

Heavy bleeding Moderate bleeding 0 2 4 6 8 10 Diode CO2 N o o f p at ie n ts

Immediate postoperative bleeding

(72)

53

ASSESMENT OF DIFFICULTY OF OPERATOR:

The difficulty of the operator was assessed intra-operatively. The difficulty of the operator for doing the procedure was easy in all the patients 10(100%) in both the technique (Chart 9).

CHART IX: DIFFICULTY OF THE OPERATOR

ASSESSMENT OF PAIN:

Pain was assessed intra-operatively, immediate post-operatively and 1st day post-operatively.Regarding pain perception in intra-operative period both the study group 10(100%) had no pain (Chart 10). In immediate postoperative period pain perception was slight in all the patient 10(100%) during both the procedures (C1art 11).Pain perception on the 1st day was slight in all the patient 10(100%) during both the procedures (Chart 12).Both the study group

experienced no pain intra-operatively and only one patient experienced mild pain in the immediate post operative period and in the 1stpost operative period.

0 2 4 6 8 10 Diode CO2 10 10

0 0

Difficulty of the operator

(73)

54

CHART X: PAIN PERCEPTION INTRA-OPERATIVELY

CHART XI: PAIN PERCEPTION IMMEDIATE POST OP PERIOD

0 2 4 6 8 10 Diode CO2 10 10

0 0

Pain perception intraoperatively

No pain With pain 0 2 4 6 8 10 Diode CO2 N o o f p at ie n ts

Pain perception immediate

postoperative period

(74)

55

CHART XII: PAIN PERCEPTION – END OF 1ST DAY

ASSESMENT OF WOUND HEALING:

Wound healing was assessed on the first, second, third, fourth week post-operatively. Wound healing at the end of 1st week was good in 2(20%) of the patients and was very good in 8(80%) of the patients in diode laser study group. In CO2 laser group the wound healing was very good

in all the patients 10(100%) (Chart14). At the end of 2nd week wound healing was very good in 8(80%) of the patients and was excellent in 2(20%) of the patients in diode laser study group. In CO2 laser group the wound healing was very good in 6(60%) the patients and excellent in

4(40%) of the patients (Chart 15).All the patients in both the study group had excellent wound healing at the end of 3rdweek (Chart 16).During the 1st and 2nd week of post operative period CO2

laser had better wound healing when compared to diode laser group but at the end of 3rd week and 4th week both the study group had excellent wound healing.

0 2 4 6 8 10 Diode CO2 10 10

0 0

Pain perception at the end of 1st day

(75)

56

CHART XIII: WOUND HEALING – END OF 1ST WEEK

CHART XIV: WOUND HEALING – END OF 2

ND WEEK 0 2 4 6 8 10 Diode CO2 2 0 8 10 N o o f p at ie n ts

Wound healing at the of 1st week

Good Very good 0 2 4 6 8 Diode CO2 8 6 2 4 N o o f p at ie n ts

Wound healing at the end of 2nd

week

(76)

57

CHART XV: WOUND HEALING – END OF 3RD WEEK

CHART XVI: WOUND HEALING – END OF 4TH WEEK

ASSESSMENT OF ESTHETIC OPINION:

The esthetic perception was assessed at the end of 4th week. All the patients 10(100%) had beautiful aesthetics in diode laser study group. In CO2 laser study group 2(20%) had better

0 2 4 6 8 10 Diode CO2

0 0

10 10

Wound healing at the end of 3rd

week

Very good Excellent 0 2 4 6 8 10 Diode CO2

0 0

10 10

Wound healing at the end of 4th

week

(77)

58

aesthetics and 8(80%) had beautiful aesthetic appearances (Chart 17).Regarding the aesthetic consideration diode laser group scored more satisfaction than CO2 laser study group.

CHART XVII: AESTHETIC OPINION OF THE PATIENT

STATISTICAL ANALYSIS

Descriptive statistics:

Measures of central tendency Eg: Mean and Measures of Dispersion Eg.

Standard deviation was calculated for all the parameters.

Inferential Statistics:

To compare the mean difference between the two groups for difference in the colour of the gingiva, bleeding, difficulties of the operator, pain perception of patient and post-operative wound healing.unpaired student ‘t’ test was used

0 2 4 6 8 10 Diode CO2 0 2 10 8 N o o f p at ie n ts

Aesthetic opinion of the patient

(78)

59

P value of 5% was considered significant.

Significance level interpretation:

NS – Not significant

Management of Gingival Hyperpigmentation using Diode Laser and Co2 Laser Therapy: A Comparative study