I research _ hyper-pigmentation

_Introduction

The colour of the gingiva is determined by sev-eral factors, including the number and size ofblood vessels, epithelial thickness, quantity of ker-atinisation and pigments within the epithelium.Melanin, carotene, reduced haemoglobin andoxyhaemoglobin are main pigments contributingto the normal colour of the oral mucosa.1 Fre-quently, the gingival hyper-pigmentation iscaused by excessive melanin deposits mainly lo-cated in the basal and supra-basal cell layers of theepithelium.2

Melanin is produced by specific cells—melanocytes residing in the basal layer—and istransferred to the basal cells, where it is stored inthe form of melanosomes. It can also be found inkeratinocytes of gingival epithelium.3

Melanin hyper-pigmented gingiva is an aes-thetic problem for many individuals, particularly ifthe hyper-pigmentation is on the facial aspect ofgingiva and visible during smiling and speech, es-

pecially those with gummy smiles.2 The degree ofpigmentation depends on a variety of factors, par-ticularly the activity of melanocytes. Fair-skinnedindividuals are very likely to have non-pigmentedgingival, but in darker-skinned persons, thechance of having pigmented gingiva is extremelyhigh. The highest rate of gingival pigmentationhas been observed in the area of incisors. The ratedecreases considerably in the posterior regions.4

Gingival depigmentation has been carried outusing surgical, chemical, electrosurgical andcryosurgical procedures.2, 5 Recently, laser abla-tion has been recognised as one of the most effec-tive, pleasant and reliable techniques.5 Many lasersystems such as Q-switched ruby laser, flash-lamppumped-dye laser, argon laser, CO2 laser, Nd:YAGlaser and Er:YAG laser have been used for skin pig-mentation.1, 2, 5

In the late 1990s, the Er,Cr:YSGG laser with awavelength of 2,780 nm, frequency of 10 to 50 Hz,and pulse energy between 0 and 300 mJ was in-troduced as a safe and efficient wavelength to be

Treatment of gingival hyper-pigmentation withthe Er,Cr:YSGG laserClinical observation and one-year follow-up

Authors_Drs Gizem Berk, Kubra Atici & Nuket Berk, Turkey

06 I laser4_2011

Fig. 2Fig. 1

research _ hyper-pigmentation I

used on hard and soft periodontal tissues, sup-ported by several published studies regarding itsbeneficial effect in periodontal treatment.6, 7

Re-pigmentation after gingival depigmentationis an important point of which clinicians should beaware. Reports of re-pigmentation are quite lim-ited and varied.1

The following case shows successful depigmen-tation using an Er,Cr:YSGG laser and results re-garding re-pigmentation obtained after a one-yearfollow-up period.

_Case report

A 29-year-old female, Turkish patient presentedto our clinic who was not happy with her smile andaesthetic appearance owing to the pigmented re-gions, most pronounced in the anterior region. Shehad extensive pigmentation on her maxillary gin-giva and moderate pigmentation on her mandibu-lar gingiva (Fig. 1). The colour of the gingiva wasdark to black. There was no contributory medicalproblem. The patient was very fearful of dental in-jections.

Preoperative pictures were taken and topicalanaesthetic gel applied to the operatory field. Incompliance with FDA rules, patient and staff usedspecial eyeglasses for protection.

Er,Cr:YSGG laser application started with 600 sapphire tips (MG6, 6 mm) with 20 Hz, 140 s pulseduration (H mode) and 1.5 W, 20 % air and 15 % wa-ter in non-contact mode, about 1.5 mm away from

the tissue and with a sweeping motion localisedonly on the pigmented regions. The procedure wasperformed in a cervico-apical direction on all pig-mented areas. After slight removal of the connec-tive tissue, the setting was changed to 1.75 W, 40 %air and 5 % water in order to obtain more rapid ab-lation with less haemorrhaging but without ther-mal damage to the tissue.

Every five minutes, the operation field waswiped with sterile gauze soaked in 1 % normalsaline solution. The depigmentation procedurecontinued until no visible pigments remained. Thecomplete treatment was performed in 30 min.

After wiping of the operative fields for the lasttime, there was slight bleeding (Fig. 2).

No periodontal pack or additional material wasapplied to support the healing procedure.

The patient was recalled 24 hours, four days andseven days later and intra-oral pictures were taken(Fig. 3).

The patient was instructed to avoid smoking, al-cohol, acidic beverages, and hot and spicy foods. Hewas advised to keep his wound area clean by brush-ing with a soft brush for the first week. No analgesicwas prescribed.

_Clinical results

After 24 hours, the lased gingiva was partly cov-ered with a thin layer of fibrin, which exfoliatedduring the first week after treatment. The ablated

I 07laser4_2011

Fig. 4Fig. 3

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I research _ hyper-pigmentation

wound was healed almost completely after fourdays. The colour of ablated gingiva was pink andhealthy four days after ablation. The gingiva was vi-sually similar to the normal untreated gingiva,completely without melanin pigmentation.

On the fourth day post-operatively, the patientwas asked whether she had had any pain or dis-comfort within the past four days. She revealedthat she had had a slight sensitivity on her maxillaabout twelve hours post-operatively but did notneed any medications and this did not cause anychange in her usual routine. The patient was re-called six months and one year later, and intra-oralpictures were taken again (Fig. 4).

_Discussion

Numerous authors have reported successful re-sults for the use of the lasers in hard and soft tissueapplications. They include procedures common tooral surgery, oral pathology, restorative dentistryand periodontics.6–9 There is abundant evidencethat confirms markedly less bleeding, particularlyof highly vascular oral tissues with laser surgery.Anecdotal reports that incising oral soft tissue witha laser is less painful then using a scalpel and there-fore requires less oral aesthetic have no scientificconfirmation to date.10 In our study, topical aes-thetic gel was applied, but no infiltration anaes-thetic was used and we observed less bleeding dur-ing laser therapy compared with conventional sur-gical techniques. Post-operative pain from oral andotolaryngological surgical procedures has beenclaimed to be reduced in laser surgery. It is theorisedthat this may be due to protein coagulum that isformed on the wound surface, thereby acting as abiological wound dressing10, 11 and sealing the endsof the sensory nerves.12 In the present study, patientsatisfaction was high. There was no complaint ofpain during treatment or post-operatively.

Some reports suggest that laser-createdwounds heal more quickly and produce less scar tis-sue than conventional scalpel surgery.13, 14 In con-trast, some studies have shown the delay of re-ep-ithelisation of the laser wound compared with con-ventional wounds.15, 16 In our report about depig-mentation treatment with the Er,Cr:YSGG laser,re-epithelisation was completed after seven daysand the gingiva was similar to the normal untreatedgingiva.

Re-pigmentation after depigmentation hasbeen reported following the use of different tech-niques. The mechanism of re-pigmentation is notunderstood but according to the migration theory,active melanocytes from the adjacent pigmented

tissues migrate to treated areas, causing re-pig-mentation.17 Dummett and Bolden18 observed par-tial recurrence of hyper-pigmentation in six out ofeight patients after gingivectomy at one to fourmonths, whereas Perlmutter and Tal17 describedpartial recurrence after seven to eight years. Tal et al.19 and Tal20 did not observe re-pigmentationuntil 20 months after cryosurgical depigmentation.No recurrence of hyper-pigmentation was found inany of the four patients treated by Atsawasuwan et al.2 at 11 to 13 months after gingival depigmen-tation using the Nd:YAG laser. Nakamura et al.21

reported depigmentation with the CO2 laser in tenpatients. No re-pigmentation was seen in the firstyear, but four patients showed re-pigmentation at24 months. Tal et al.1 observed no re-pigmentationin any of the patients treated with the Er:YAG laserafter six months.

In the present study, re-pigmentation was notobserved during a one-year follow-up period.However, long-term observations are required todetermine the efficiency of the Er,Cr:YSGG laser inhyper-pigmentation treatment.

_Conclusion

Treatment of gingival hyper-pigmentation byEr,Cr:YSGG laser radiation in a defocused mode wasfound to be a safe and effective procedure. Post-operative patient satisfaction in terms of aestheticand pain was impressive. The gingiva healed un-eventfully and completely regenerated with no in-fection, pain, swelling or scarring. No re-pigmenta-tion had occurred after one year post-surgery.Based on these observations, the Er,Cr:YSGG laser isa good treatment choice for gingival hyper-pig-mentation._

Editorial note: A list of references is available from the

publisher.

08 I laser4_2011

Dr Gizem Berk

Denta Form Health Center

Mahatma Gandi Cad. No. 34

06700 G.O.P.

Ankara, Turkey

Tel.: +90 312 4476090

Fax: +90 312 4462782

gizemberk@yahoo.com

www.dentaform.com.tr

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