The Waterlase MD from Biolase.
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T echnology makes it possible to apply minimally invasive dentistry to many areas of care. Lasers have become more common in dentistry, are used in virtually every aspect of our profession and they’re being used in more creative ways than ever before.

I recently used an Er,Cr:YSGG laser to accomplish the cosmetic depigmentation of the gingiva. I had used the Waterlase MD (Biolase Technology Inc.) for many years to treat caries and periodontal disease, as well as to perform osseous surgeries and cosmetic gingival recontouring procedures, but never to cosmetically lighten gingival hyperpigmentation.

Before beginning, I consulted with local periodontists and a few of my laser mentors, though none of them had treated a similar case. I also referenced several articles in the Journal of Periodontology.1-4 The authors successfully treated similar cases using both Nd:YAG and Er:YAG lasers with little or no apparent recurrence of the pigmentation, but they occasionally had to re-treat small areas that did not respond to the first treatment phase.

The following case illustrates how I used the Waterlase MD to achieve depigmentation of the gingiva, giving my patient a more esthetic smile using a minimally invasive technique.

THE PROBLEM

A 33-year-old woman presented for treatment, with her “discolored teeth and gums” her chief concern. She “hated” her gums and expressed interest in having whiter, straighter teeth. She is of Hawaiian decent and said her gum tissue was pink until it began to “discolor” when she was a teenager. Her medical history was not contributory, but she does smoke cigarettes.

An examination with full-mouth radiographs and periodontal charting was completed. This showed she had some occlusal carious lesions. Her periodontal health was good, with only a few bleeding sites noted and no significant pocketing. The lower anterior teeth were crowded and there was stain noted on them. The base shade of her upper anterior teeth was A-1.0.

The gingival tissue was dark blue-black and a hyperpigmentation diagnosis was established (Figs. 1 and 2). It should be noted that the patient had a high smile line, with several millimeters of gingival tissue on both upper and lower arches.

THE TREATMENT

We discussed treatment options including cleaning and whitening, cosmetic veneers and orthodontic treatment, although it was not certain whether the hyperchromatic gum tissue could be changed. She elected to have a consultation with an orthodontist to straighten her lower teeth. She may also do elective bleaching, although I suggested her teeth were already very light. She completed a prophylaxis and treated the caries with composite restorations. After all this was done, she still was interested in lightening her gums.

I initially treated a small area between two lower bicuspids and found excellent results when I evaluated the patient three weeks later. The definitive treatment involved a local anesthetic. I used the laser with a C-12 tip at 1.75W, 11% air, 4% water, 30pps, in H mode.

Using six power magnification loupes,5 I worked over about a 5 mm by 5 mm area at one time, initially de-epithelializing the gingiva, then progressing slightly deeper until the pigmented cell layers appeared and subsequently were ablated. I treated the upper arch, from the first bicuspid to the contralateral first bicuspid. Treatment time was about one hour, 15 minutes.

The gingiva, at this point, appeared slightly red. The blue-black color was gone, there was no bleeding and no charring as noted in some reference articles (Fig. 3). No periodontal dressing was placed and no sutures were used. The patient was advised not to smoke for 72 hours, and to use ibuprofen and over-the-counter topical anesthetic for pain.

THE RESULT

The patient was evaluated at four weeks and was extremely pleased with the results of her treatment. There was normal healing noted at this time. The gingiva had re-epithelialized and was a normal shade of dark pink (Figs. 4 and 5). There was no abnormal inflammation of the periodontium or other gingival defect, and she reported no pain or other discomfort.

The patient indicated she had no pain for the first 48 hours after treatment. She did experience “some soreness for about 10 days,” which was controlled by the ibuprofen. She also reported “a white film that sloughed” between days 6 to 8. Once this treatment was complete, the patient indicated she was anxious to treat the lower arch as soon as possible.

This simple, minimally invasive, cosmetic procedure provided excellent results for this patient. I believe the Waterlase MD, with its water-cooling effect, is well suited for this application.
 

Before treatment
Fig. 1 Pre-operative appearance. Note the extremely dark pigmented gingiva.	Fig. 2 Pre-operative appearance, frontal view.
After treatment
Fig. 3 Immediate post-operative appearance. Note the absence of bleeding or charring and the apparent elimination of the pigmentation.	Figs. 4 and 5 Appearance at one month post-op. The maxillary gingiva now demonstrates normal coloration and gingival health.
Photos courtesy of Dr. J.C. Goodwin

	Dr. J.C. Goodwin is a general dentist, holds Fellowship status with the WCMID and has been using an Er,Cr:YSGG dental laser since 2005. He has been in private practice in Prescott, Ariz. since 1987 and has special interest in non-surgical periodontal therapy and other laser treatment techniques. He can be reached at 928-308-0820.
	This monthly column is co-sponsored by DPR and The World Congress of Minimally Invasive Dentistry. It is edited by Congress past-president Dr. Joseph Whitehouse.

 

1. Rosa DSA, Correa Aranha AC, de Paula Eduardo C, Aoki A. Esthetic Treatment of Gingival Melanin Hyperpigmentation With Er:YAG Laser: Short-Term Clinical Observations and Patient Follow-Up. J Periodontal 2007;78:2018-25.

2. Azzeh MM. Treatment of Gingival Hyperpigmentation by Erbium-Doped:Yttrium, Aluminum, and Garnet Laser for Esthetic Purposes. J Periodontal 2007;78:177-84.

3. Tal H, Oegiesser D, Tal M. Gingival Depigmentation by Erbium:YAG Laser: Clinical Observations and Patient Responses. J Periodontal 2003;74:1660-7.

4. Atsawasuwan P, Greethong K, Nemmanon V. Treatment of Gingival Hyperpigmentation for Esthetic Purposes by Nd:YAG Laser: Report of 4 Cases. J Periodontal 2000;71:315-21. 5. Millar BJ. Focus on Loupes. Br Dent J 1998;185:504-8.