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ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 59-64

Comparison of efficacy of depigmentation of gingiva in terms of ImageJ intensity values and surface area of repigmentation using scalpel and diode laser


Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Puducherry, India

Date of Web Publication13-Feb-2017

Correspondence Address:
M Jananni
Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.199988

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  Abstract 

Background: For an attractive smile, health and color of the gingiva are essential components. Hyperpigmented gingiva is considered unaesthetic and unsightly by many, and there is an increasing demand for depigmentation of gingiva from patients. Many techniques are available for gingival depigmentation. Aims and Objectives: To compare the effectiveness of scalpel and laser techniques for depigmentation in terms of patient comfort using visual analog scale (VAS) for pain, changes in ImageJ intensity values of gingival pigmentation, and to compare the frequency and area of repigmentation postoperatively between two groups up to a period of 3 months using Adobe Photoshop. sMaterials and Methods: The study was conducted in the Department of Periodontics, Indira Gandhi Institute of Dental Sciences. Fifty individuals, aged between 18 and 30 years, with an esthetic complaint of hyperpigmented gingiva were enrolled in the study. The study comprised two groups of 25 individuals each. One group was taken up for scalpel method of depigmentation and the other for laser depigmentation. Results: The difference between the mean pain scores of scalpel and laser group on day 1, day 4, and day 7 were recorded, with a P value of 0.123, 0.000, and 0.037, respectively. The difference in intensity values between baseline and 90 days for both scalpel and laser groups was highly significant, with a P value of 0.000. When surface area of repigmentation was compared between two groups, scalpel group (557.20 mm2) of patients had less repigmentation than laser group (737.08 mm2). Conclusion: The patient apprehension for anesthetic infiltration, bleeding during the procedures, and VAS scores for pain were less in laser group as compared to scalpel group. Efficiency of depigmentation and frequency of recurrence of gingival pigmentation were similar in both the groups. However, in terms of patient's comfort, laser appeared to have a significant advantage over scalpel.

Keywords: Esthetics, gingival pigmentation, ImageJ, laser, repigmentation, scalpel


How to cite this article:
Raaman A R, Pratebha B, Jananni M, Saravanakumar R. Comparison of efficacy of depigmentation of gingiva in terms of ImageJ intensity values and surface area of repigmentation using scalpel and diode laser. Int J Oral Health Sci 2016;6:59-64

How to cite this URL:
Raaman A R, Pratebha B, Jananni M, Saravanakumar R. Comparison of efficacy of depigmentation of gingiva in terms of ImageJ intensity values and surface area of repigmentation using scalpel and diode laser. Int J Oral Health Sci [serial online] 2016 [cited 2017 Apr 26];6:59-64. Available from: http://www.ijohsjournal.org/text.asp?2016/6/2/59/199988


  Introduction Top


The esthetics of smile though majorly influenced by the color, shape, and position of the teeth is also influenced by the color of the gingival tissues. The color of gingiva is influenced by the vascular supply, thickness and degree of keratinization of the epithelium, and presence of various pigments.[1] Among these, the major factor contributing to the color of gingiva is melanin, a brown endogenous pigment.

Melanin hyperpigmentation of the gingiva does not pose any medical problem, but many patients may consider this an esthetic problem, particularly patients who have excessive gingival display or gummy smile.[2],[3] In such cases, the excessive melanin pigmentation can be corrected by a simple periodontal plastic procedure known as gingival depigmentation.

Over the years, many techniques for gingival depigmentation have been developed that includes deepithelization (scalpel and gingival abrasion technique using diamond bur), gingivectomy, gingivectomy with free gingival autografting, acellular dermal matrix allograft, electrosurgery, cryosurgery, chemical agents, and lasers.[4] Scalpel deepithelization is the first described, simple, and most economic procedure. Since the advent of lasers, they have been effectively used for the same.

Several studies have been done to compare the efficacy of lasers and scalpel depigmentation techniques, but the extent of depigmentation achieved has been measured subjectively in terms of color changes.[5] An objective method of assessing the changes in the intensity values of melanin pigmentation of gingiva pre- and post-operatively after depigmentation has not been done. There are also very few studies on frequency of repigmentation of gingiva after laser and scalpel depigmentation procedures.

In lieu with the above, the present study is undertaken to compare the clinical efficacy of surgical scraping using scalpel and diode laser in terms of patient comfort, melanin intensity values using ImageJ software and to quantify repigmentation of the surgical site up to a period of 3 months.

Aims and objectives

To compare effectiveness of scalpel and laser techniques for depigmentation in terms of:

  1. Patient's comfort using visual analog scale (VAS) for pain
  2. Changes in intensity values of gingival pigmentation at baseline and at 30th and 90th day follow-up period using ImageJ analysis.
  3. To compare the frequency and area of repigmentation postoperatively between two groups up to a period of 90 days using Adobe Photoshop CS2.



  Materials and Methods Top


The study was conducted in the Department of Periodontics, Indira Gandhi Institute of Dental Sciences. The study was approved by the Institutional Ethical Committee (Ref code: IGIDSIRB 2014PERIO3PGARDP). Fifty individuals, aged between 18 and 30 years, with a complaint of unaesthetic gingival color were enrolled in the study. The enrolled individuals were randomly distributed into two groups:

  1. Group A (n = 25) – depigmentation using scalpel technique
  2. Group B (n = 25) – depigmentation using laser technique.


All the study participants were briefed about the surgical procedure and informed consent was obtained.

Inclusion criteria

Individuals with hyperpigmented gingiva were included in the study.

Exclusion criteria

Former and current smokers, patients with compromised systemic health (Peutz-Jeghers and Laugier-Hunziker syndromes, Addison's disease, Albright's syndrome, hemochromatosis, generalized neurofibromatosis, Whipple's disease, Wilson's disease, Gaucher's disease, antimalarial drugs, human immunodeficiency virus infection, thalassemia, and jaundice), pregnant women, and lactating women were excluded from the study.

Scalpel depigmentation technique

The area of melanin hyperpigmentation (area of interest from distal aspect of maxillary right canine to left canine) was marked by two vertical and horizontal lines for demarcating it from the uninvolved area. Local infiltration was done using local anesthetic solution Lignox ® (2% lignocaine with 1:200,000 adrenaline). No. 15 or no. 11 surgical grade blade on a Bard-Parker handle was used for surgical stripping.[6]

Laser depigmentation technique

Topical anesthetic gel was applied to the surgical field. Local infiltration with anesthetic solution Lignox ® (2% lignocaine with 1:200,000 adrenaline) was given only when discomfort was experienced by the patient. All the necessary precautions and protective measures for the use of lasers were done. The properly initiated tip of the diode laser unit (Zolar soft-tissue diode laser with wavelength range 810–980 nm) was angled at an external bevel of 45°. 1.5–2 W continuous wave was used with small brush-like strokes. Gradual progression deeper along the same initial laser incision was done to remove the tissue. Laser ablation began at the mucogingival junction toward the free gingival margin, including interdental papillae. Tissue irradiated until the lased area demonstrated an opaque white appearance.[7]

Calculation of surface area of gingival pigmentation and repigmentation

Standardized photographs were taken from which image was cropped from right to left mid cervical region. Grid lines were drawn with each square measuring 1 cm 2. The pigmented areas were colored green, and the area of pigmentation in cm 2 was counted and recorded. Base line 30th and 90th day, photographs were taken and the area of repigmentation was colored yellow and the surface area was calculated [Figure 1].[8]
Figure 1: (a) Grid superimposed over preoperative image. (b) The pigmented area coded with green and surface area counted. (c) Grid superimposed over postoperative image. (d) The repigmented area coded with yellow and surface area counted

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Calculation of darkness value of gingiva using ImageJ intensity values

Standardized photographs were taken, and the gingiva extending from the left and right mid cervical region of the maxillary canine was cropped using Adobe Photoshop. The distance between these two points were standardized to 10 cm and the area of interest cropped using polygonal lasso tool. The cropped image was introduced into ImageJ software, and the intensity values were calculated [Figure 2].[9]
Figure 2: (a) Cropping the pigmented area with lasso tool. (b) The cropped area to be analyzed. (c) Analysis done with ImageJ software using histogram portion. (d) The histogram

Click here to view



  Results Top


Pain

VAS for pain was assessed on the 1st, 4th, and 7th day postoperatively. Patients of both the groups were advised to use analgesics only if pain was unbearable. On day 1, 16% out of 50 patients had no pain, of which 12% patients belonged to Group B. On day 4, 36% out of 50 patients had no pain, out of which 30% belonged to Group B. On comparing VAS scores for both the groups on 7th day: 92% out of 50 patients had no pain, out of which 50% belonged to Group B and 42% belonged to Group A. Comparing the groups on day 1, there was no significant difference. However, on day 4 and day 7, the difference between the groups was statistically significant [Table 1].
Table 1: Comparison of visual analog scale scores between the groups

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Comparison of darkness melanin intensity

Darkness value of gingival pigmentation can be calculated using ImageJ software which has readings, from 0 to 255.0 indicating pure dark and 255 indicating pure white.

In our study, in Group A, the mean intensity values at baseline and 30th and 90th day were 172.15 ± 12.830, 195.58 ± 10.516, and 187.86± 9.38. In Group B, the mean intensity values at baseline and 30th and 90th day were 172.21 ± 11.216, 194.49 ± 8.390, and 187.62 ± 7.749, respectively [Table 2]. Differences in intensity values from baseline to 90th day in Group A was 15.771 ± 8.780 and Group B was 15.411 ± 7.393. The differences between the group were not statistically significant (P = 0.165) [Table 3].
Table 2: Mean darkness value of gingiva at baseline and 30th and 90th day

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Table 3: Comparison of difference in mean intensity values between the groups

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Comparison of repigmentation

The mean surface area of pigmentation in Group A at baseline was 1743.1 mm 2 and that of Group B was 1680.92 mm 2. The mean surface area of two groups at baseline was almost similar. The mean surface area of repigmentation of Group A at 90th day was 557.20 and that of Group B was 737.08. The difference between two groups in surface area of repigmentation at 90th day was clinically appreciable with scalpel group having lesser surface area of repigmentation; however, statistically, it was not significant (P = 0.085) [Table 4].
Table 4: Comparison of area of repigmentation between groups from baseline to 90th day

Click here to view



  Discussion Top


Hyperpigmented gingiva is considered unaesthetic and unsightly by many, and there is an increasing demand for depigmentation of gingiva from patients. Many techniques are available for gingival depigmentation, of which surgical stripping is considered as a gold standard. Use of laser for depigmentation has gained more attention in the past decade.

For comparison of mean pain scores between the two groups, mild, moderate, and severe pain were combined into a single category as pain, and then, mean VAS for pain was compared between two groups on day 1, 4, and 7. Although clinically there was difference in total number of patients experiencing pain between scalpel (n = 23) and laser groups (n = 19) on day 1, it was statistically not significant (P = 0.123). However, on day 4 and day 7, the VAS scores between the groups were statistically significant (P = 0.001 and P = 0.037) [Table 1].

The reason for laser groups of patients experiencing less pain is probably due to protein coagulum formed on the wound surface, which served as a biological wound dressing and sealing the ends of sensory nerves.[4],[5],[6] Our study results were in accordance with the study done by Gunamoorthy et al. and Lagdive et al., where they compared scalpel and diode laser group for pain scores and reported that diode laser group of patients experiencing significantly less pain compared to scalpel group.[7],[5]

In addition to VAS scores, the general experience of patients during the procedure by both the techniques was noted down. Their experience as reported by them was as follows: It appears that they were more apprehensive to anesthetic administration (infiltration) and bleeding during the procedure. While in the laser group, patients reported the burning smell as nonagreeable. In both the groups, the patient appeared comfortable throughout the procedure.

For assessing the effectiveness of depigmentation by both the techniques, the darkness melanin intensity values and the surface area of repigmentation were calculated.

The darkness intensity values were recorded using ImageJ Software. The difference in mean intensity values for Group A from baseline to 30th day & 30th day to 90th day was statistically significant (P = 0.000 and P = 0.000, respectively). When difference in intensity values between baseline and 90th day was analyzed, a significant difference was obtained (P = 0.000) [Table 2] and [Table 3]. Similar results were obtained in Group B also. Our study results were in accordance with the study done by Saraffsirazi et al.[10] They compared the mean darkness values for depigmentation procedure done by cryosurgery at 3, 12, and 24 months and reported that statistical difference was found in gingival color between preoperative and postoperative follow-up at 3, 12, and 24 months.

Repigmentation was assessed in both the groups by calculating the surface area (mm 2) of pigmented tissues by superimposing a grid over the postoperative photographs using Adobe Photoshop CS2. The mean surface area of pigmentation in Group A at baseline was 1743.1 mm 2 and that of Group B was 1680.92 mm 2. The mean surface area of two groups at baseline was almost similar. At 90th day, the mean surface area of repigmentation in Group A was 557.20 mm 2 and that of Group B was 737.08 mm 2. The difference between two groups in surface area of repigmentation at 90th day was clinically appreciated, but no statistical significance was obtained (P = 0.085) [Table 4].

According to our study, repigmentation in scalpel group was slightly lesser compared to laser group. The reason could be that scalpel depigmentation reaches deeper layers of connective tissues and is more thorough. When laser is used for ablation of pigmented tissues, it is restricted to superficial layers of gingival epithelium. Therefore, inadequate penetration of laser beam probably resulted in faster repigmentation in the interdental papilla and marginal gingiva. Thorough depigmentation could be achieved with scalpel compared to laser; improper deepithelialization in marginal gingiva and interdental papilla could result in deformation. In addition, Hegde et al. in their study mentioned that scalpel techniques caused larger layer of cell death compared to laser.[11]

We observed repigmentation was faster in patients with darker complexion, which was in accordance with the studies done by Harjitkaur et al. and Raut et al.[12],[13] In our study, on 30th day, all the patients in both groups had milder repigmentation, which was in accordance with the study done by Ginwalla et al., who reported 50% of depigmented patients had recurrence between 24 and 55 days.[14] Dummet and Bolden also observed study partial recurrence of hyperpigmentation in six out of eight patients at 1–4 months.[15]

On contrary, in other studies done by Tanuja et al.,[16] Kharkar et al.,[17] and Allen et al.,[18] no repigmentation was observed in patients treated with diode laser up to a follow-up period of 3, 6, and 5 months, respectively. The reason for lack of repigmentation as cited by Hegde et al. might be either migration of melanocytes did not occur during the period or melanocytes that had migrated were not active and genetic influence on repigmentation could not be conclusively analyzed.[11]

In our study, we observed that the order of reappearance of pigmentation mostly involved interdental papilla followed by marginal gingiva and attached gingiva. This observation was in accordance with the study done by Hegde et al.[11] They reported that reason for repigmentation to occur frequently in interdental papilla in both the groups could be due to the following reasons:

  1. Adequate depigmentation in the papilla and marginal gingiva was difficult to achieve particularly with lasers due to the fact that marginal gingiva is thinner and there is a risk of ablation of marginal gingival tissue
  2. In the interdental gingiva, due to the increased thickness, high wattage is required for adequate depigmentation. However, this could not be done due to risk of thermal damage to underlying tooth structures.


Depigmentation procedures cannot afford permanent cosmetic results. Repigmentation of gingiva bound to happen sooner or later due to the nature of melanocytes. Even when melanocytes are locally depleted during depigmentation, they tend to repopulate. According to migration theory, melanocytes from normal tissues migrate and proliferate into the depigmented areas resulting in repigmentation.


  Conclusion Top


Esthetic gingival depigmentation procedures can establish better cosmetic results and is considered a boon for patients having hyperpigmented gingiva. Apart from cryosurgery, two most effective techniques for depigmentation are surgical stripping using scalpel and laser. Gingival depigmentation procedures can be considered successful if there is delayed, minimal, or no recurrence of gingival pigments.

In our study, it was observed that patient apprehension for anesthetic infiltration, bleeding during the procedures, and VAS scores for pain were less in laser group as compared to scalpel group. Efficiency of depigmentation and frequency of recurrence of gingival pigmentation were similar in both the groups. However, in terms of patient's comfort, laser appeared to have a significant advantage over the scalpel.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tal H, Oegiesser D, Tal M. Gingival depigmentation by erbium: YAG laser: Clinical observations and patient responses. J Periodontol 2003;74:1660-7.  Back to cited text no. 1
    
2.
Roshna T, Nandakumar K. Anterior esthetic gingival depigmentation and crown lengthening: Report of a case. J Contemp Dent Pract 2005;6:139-47.  Back to cited text no. 2
    
3.
Azzeh MM. Treatment of gingival hyperpigmentation by erbium-doped: Yttrium, aluminum, and garnet laser for esthetic purposes. J Periodontol 2007;78:177-84.  Back to cited text no. 3
    
4.
Cohen ER, Ammons W. Laser in periodontics (Position paper). J Periodontol 1996;67:826-30.  Back to cited text no. 4
    
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Rossmann JA, Cobb CM. Lasers in periodontal therapy. Periodontol 2000 1995;9:150-64.  Back to cited text no. 5
    
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Schuller DE. Use of the laser in the oral cavity. Otolaryngol Clin North Am 1990;23:31-42.  Back to cited text no. 6
    
7.
Kaarthikeyan G, Nadathur D, Jayakumar ND, Padmalatha O, Sheeja V, Richa K. Pain assessment using a visual analogue scale in patients undergoing gingival depigmentation by scalpel and 970-nm diode laser surgery. J Laser Dent 2012;20:20-3.  Back to cited text no. 7
    
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Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.  Back to cited text no. 8
    
9.
Raghu R, Pratebha B, Jananni M, Kumar S. Image J intensity values to objective Dummett Gupta classification of physiologic gingival pigmentation. Clin Adv Periodontics 2015;5:143-6.  Back to cited text no. 9
    
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Shirazi AS, Moeintaghavi A, Khorakian F, Talebi M. Treatment of gingival physiologic pigmentation in adolescents by liquid nitrogen cryosurgery: 24-month follow-up. Int J Periodontics Restorative Dent 2012;32:e142-6.  Back to cited text no. 10
    
11.
Hegde R, Padhye A, Sumanth S, Jain AS, Thukral N. Comparison of surgical stripping; erbium-doped: Yttrium, aluminum, and garnet laser; and carbon dioxide laser techniques for gingival depigmentation: A clinical and histologic study. J Periodontol 2013;84:738-48.  Back to cited text no. 11
    
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Kaur H, Jain S, Sharma RL. Duration of reappearance of gingival melanin pigmentation after surgical removal – A clinical study. J Indian Soc Periodontol 2010;14:101-5.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
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Raut RB, Baretto MA, Mehta FS, Sanjana MK, Shourie KL. Gingival pigmentation: Its incidence amongst the Indian adults. JAIDA 1954;26:9-10.  Back to cited text no. 13
    
14.
Ginwalla TM, Gomes BC, Varma BR. Surgical removal of gingival pigmentation. (A preliminary study). J Indian Dent Assoc 1966;38:147-50.  Back to cited text no. 14
    
15.
Dummett CO, Bolden TE. Post surgical clinical repigmentation of the gingiva. J Oral Surg Oral Med Oral Pathol 1963;16:353-65.  Back to cited text no. 15
    
16.
Tanuja P, Babu BK, Krishna MT. Laser-assisted crown lengthening and gingival depigmentation to enhance aesthetics – A case report. Ann Essent Dent 2011;3:56-9.  Back to cited text no. 16
    
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Khakhar M, Kapoor R, Jayakumar ND, Padmalatha O, Varghese SS. Advantages of 980-nm diode laser treatment in the management of gingival pigmentation. J Laser Dent 2011;19:283-5.  Back to cited text no. 17
    
18.
Allen EP, Gladkova ND, Fomina YV, Karabut KG, Kiseleva EB, Feldchtein FI, et al. Successful gingival depigmentation with laser-patterned microcoagulation: A case report. Clin Adv Periodontics 2011;1:210-4.  Back to cited text no. 18
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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