Journal of Cosmetic and Laser Therapy, 2010; 12: 7780

CASE REPORT

Use of 532-nm Q-switched Nd:YAG laser for smokers gingival hyperpigmentation

SUNG BIN CHO1, JU HEE LEE1, WOONKYUNG SEO2 & DONGSIK BANG1
of Dermatology and Cutaneous Biology Research Institute,Yonsei University College of Medicine, Seoul, Korea and 2Department of Oromaxillofacial Surgery, Armed Forces Yangju Hospital,Yangju, Korea
Abstract Laser treatments using 532-/1064-nm Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers are popular non-ablative and selective photothermolysis therapies for pigmentary disorders. We treated three male Korean patients (aged 23, 27 and 24 years) for smokers gingival hyperpigmentation using a 532-nm Q-switched Nd:YAG laser. At each treatment session, the laser was delivered at 1.2 J/cm2 with a 5-mm spot size and appropriate overlap. Clinical improvement as well as complete healing of the treated gingiva was noted within 2 weeks after each treatment. We also observed that the therapeutic effects lasted more than 6 months. Key words: Gingival hyperpigmentation, Nd:YAG laser, smoker
1Department

Introduction Oral mucosal pigmentation has been linked to several factors including population variation, drugs, active or second-hand smoking, heavy drinking, hormones, Addisons disease, and malignancies (13). Physiologic changes of oral pigmentation are noted in individuals with a darker skin, pregnant women, and women with hormone replacement therapy. Patients with multiple labial melanotic macules should be ruled out of the possibly associated conditions such as Peutz-Jeghers syndrome, Carney complex, and Laugier-Hunziker syndrome, although lentigines commonly occur on the palate, gingiva, and lips. The noxious effects of cigarette smoking on the periodontium have been extensively reported; including the increased risks of periodontal destruction, alveolar bone loss, subgingival infection, gingival bleeding, gingivitis, and hyperpigmentation (47). Although the cessation of smoking can slow the disease progression of any smoking-related periodontal diseases, it is suggested that quitting smoking does not reverse the past effects of smoking on periodontal tissues (4). The present study describes the clinical effects and safety of 532-nm Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser treatment, which is a non-ablative and selective

photothermolysis laser therapy, for the treatment of smokers gingival hyperpigmentation.

Case report We treated three male Korean patients (aged 23, 27 and 24 years) for smokers gingival hyperpigmentation using a 532-nm Q-switched Nd:YAG laser. The patients had no pertinent medical history other than a history of smoking (each patient had smoked approximately one pack/day for at least 3 years). The patients presented with varying degrees of diffuse brownish-pigmented patches on the upper and lower gingiva (Figures 1A, 2A, and 3A). The possibility of underlying disorders, including Addisons disease, hemochromatosis, Wilsons disease, and PeutzJeghers syndrome, had been ruled out through clinical manifestations and results of laboratory tests. After obtaining informed consent, the patients were treated with one to three sessions (patient 1: three sessions; patient 2: one session; patient 3: two sessions) of 532-nm Q-switched Nd:YAG laser therapy using a Spectra VRMIII apparatus (Lutronic, Goyang, Korea) at a month interval. The total number of treatment sessions was determined by clinical response and patient satisfaction. Laser

Correspondence: Dongsik Bang, Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, 250 Seongsanno, Seodaemoon-Gu, Seoul 120-752, Korea. E-mail: dbang@yuhs.ac

(Received 25 September 2009; accepted 9 February 2010)

ISSN 1476-4172 print/ISSN 1476-4180 online 2010 Informa UK Ltd. DOI: 10.3109/14764171003706174

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Figure 1. Patient 1 with hyperpigmented gingiva treated with three sessions of 532-nm Q-switched Nd:YAG laser (A: before the treatment; B: immediately after the rst treatment; C: 2 weeks after the nal treatment; D: 6 months after the nal treatment).

treatment was delivered to patients 1 and 2 after topical anesthesia via a 5-minute gargle with Xylocaine Pump Spray (AstraZeneca AB, Sdertlje, Sweden). Patient 3 received a lidocaine nerve block injection (inltration of 2% lidocaine mixed with 1:100 000 epinephrine) for precise anesthetic effects

(Figure 3B and C). All patients wore a mouthpiece to facilitate the procedure. Saliva and the anesthetic gargle solution were gently removed using gauze just prior to the induction of laser therapy. The laser was delivered at 1.2 J/cm2 with a 5-mm spot size and appropriate overlap.

Figure 2. Patient 2 with hyperpigmented gingiva treated with one session of 532-nm Q-switched Nd:YAG laser (A: before the treatment; B: immediately after the treatment; C: 2 weeks after the treatment; D: 6 months after the treatment).

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Figure 3. Patient 3 with gingival hyperpigmentation treated with two sessions of 532-nm Q-switched Nd:YAG laser (A: before the treatment; inltration of 2% lidocaine mixed with 1:100 000 epinephrine on the (B) upper and (C) lower gingival; D: 6 months after the nal treatment).

Immediately after the treatment, post-therapy frosts were observed (Figures 1B and 2B). Patients generally experienced a prickling sensation for 13 days post-therapy without toothache. Minimal posttherapy bleeding was noted, and quickly subsided without intervention. Patients were prescribed mouth gargle (benzydamine chloride) for 3 days post-treatment and were advised to quit smoking. Nearly all of the post-therapy crusts spontaneously fell off within 5 days. In the interim, patients were advised to avoid excessively long or vigorous tooth brushing. Clinical improvement as well as complete healing of the treated gingiva was noted within 2 weeks after each treatment (Figures 1C and 2C). Also, we observed that the therapeutic effects lasted more than 6 months (Figures 1D, 2D, and 3D). All patients were satised with the treatment outcomes. Discussion Lasers are very precise and selective treatment modalities. Various laser devices have been used in numerous periodontal procedures, such as gingivoplasty, ablation of gingival epithelium, frenectomy, excisional and incisional biopsies, and implantation (8). The laser devices, which have been widely used for the treatment of oral cavity lesions, include carbon dioxide, erbium:YAG, Nd:YAG, and diode lasers (8). Choosing laser devices depends mainly on the characteristics of target lesions, laser types, possible side effects, and operators preferences.

Because pathological studies have established that oral mucosal pigmentation is associated with basal hypermelanosis in cases of smokers melanosis (3), clinical effects can be expected with ablative laser therapies using 10 600-nm carbon dioxide or a 2940-nm erbium:YAG lasers. Chromophore, the main light-absorbing molecule of both carbon dioxide and erbium:YAG lasers, is water and these lasers can precisely vaporize the epidermis and upper dermis depending on the laser settings. Carbon dioxide lasers are one of the workhorse surgical lasers and can resurface lesions with little or no hemorrhage (9). However, the risk of side effects, such as scarring and post-therapy dyschromias, is higher with carbon dioxide lasers because the thermal effects of carbon dioxide lasers on the perilesional tissues are greater compared with those of erbium:YAG lasers. Until recently, ablative erbium:YAG lasers have been widely used for the removal of gingival melanin and discoloration (10,11). The erbium:YAG laser was approved by the US Food and Drug Administration for hard tissue treatment in dentistry and the laser has proven effective for the ablation of oral soft and hard tissue (11). However, although most of the gingiva epithelializes at 1 week after erbium:YAG treatment, complete recovery of the full tissue thickness generally takes about 24 weeks (10). Laser treatments using 532-/1064-nm Q-switched Nd:YAG lasers are popular non-ablative and selective photothermolysis therapies for pigmentary disorders in dermatological practices. A Q-switching technique

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2. Chuong R, Golgberg MH. Case 47, part II: Oral hyperpigmentation associated with Addisons disease. J Oral Maxillofac Surg. 1983;41:6802. 3. Nwhator SO, Winfunke-Savage K, Ayanbadejo P, Jeboda SO. Smokers melanosis in a Nigerian population: A preliminary study. J Contemp Dent Pract. 2007;8:6875. 4. Laxman VK, Annaji S. Tobacco use and its effects on the periodontium and periodontal therapy. J Contemp Dent Pract. 2008;9:97107. 5. Grossi SG, Zambon JJ, Machtei E, Ho AW, Dunford R, Genco RJ. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol. 1994;65: 2607. 6. Grossi SG, Genco RJ, Machtei EE, Ho AW, Koch G, Dunford R, et al. Assessment of risk for periodontal disease. II. Risk indicators for alveolar bone loss. J Periodontol. 1995;66: 239. 7. Zambon JJ, Grossi SG, Machtei EE, Ho AW, Dunford R, Genco RJ. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens. J Periodontol. 1996;67:10504. 8. Coleton SH. The use of lasers in periodontal therapy. Alpha Omegan. 2008;101:1817. 9. Sakamoto FH, Wall T, Avram MM, Anderson RR. Lasers and ashlamps in dermatology. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatricks dermatology in general medicine. 7th ed. New York: McGraw-Hill; 2007. p. 226379. 10. Rosa DS, Aranha AC, Eduardo Cde P, Aoki A. Esthetic treatment of gingival melanin hyperpigmentation with Er:YAG laser: Short-term clinical observations and patient follow-up. J Periodontol. 2007;78:201825. 11. Ishikawa I, Aoki A, Takasaki AA. Potential applications of erbium:YAG laser in periodontics. J Periodontal Res. 2004;39:27585.

emits nanosecond laser pulses by sudden releasing of the excited-state energy from a laser medium (9). With a concept of selective photothermolysis, light can pass through the epithelial or dermal cells preserving the barrier functions and creating therapeutic effect only at certain targets. Owing to its penetration depth and laser tissue absorption spectrum, the 532-nm Q-switched Nd:YAG laser is used for various epidermal pigmented lesions. The 532-/1064-nm Q-switched Nd:YAG laser has no specic light-absorbing factors on the epidermal architecture. Therefore, light can project through skin without a pronounced effect on its barrier function and patients can be treated with minimal downtime. However, optimized, prospective studies should be conducted in the future to conrm our ndings. Acknowledgement The authors report no funding sources and declare no conicts of interest. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper. References
1. Unsal E, Paksoy C, Soykan E, Elhan AH, Sahin M. Oral melanin pigmentation related to smoking in a Turkish population. Community Dent Oral Epidemiol. 2001;29:2727.

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Copyright of Journal of Cosmetic & Laser Therapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.