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33]

Original Article

Assessment of healing following

low‑level laser irradiation after
gingivectomy operations using a
novel soft tissue healing index:
A randomized, double‑blind,
split‑mouth clinical pilot study
Shreya Lingamaneni, Lohith Reddy Mandadi, 
Krishnajaneya Reddy Pathakota1

Private Practice, Abstract:

Family Dental Care, Background: Lasers have become a part of modern dentistry since the past three decades. A wide‑ranging
1
Department of assortment of lasers is being used in periodontology for both soft and hard tissue surgical procedures. Regardless
Periodontics, Sri Sai of the frequent practice of using these well‑known surgical lasers, there is another lesser familiar class of lasers
College of Dental called the low‑level lasers. The main doctrine behind using low‑level laser therapy (LLLT) is centered on the
Surgery, Hyderabad, biostimulation, or the biomodulation effect, which relies on the dexterity of low‑intensity laser energy when
irradiated at a specific wavelength, is able to modify cellular activities (increase in cell metabolism and fibroblast
Telangana, India
and keratinocyte proliferation). Aim: The aim of the present study was to investigate the adjunctive use of LLLT
on gingival healing after gingivectomy procedures. Materials and Methods: Ten systemically healthy patients
requiring gingivectomy or gingivoplasty procedures bilaterally in either the maxillary or mandibular teeth were
included in the study. After surgical intervention, a diode laser (810 nm) was randomly activated to one side of the
operated area while other side did not receive any treatment and served as the control. The healing index given
by Landry et al. was used to evaluate the soft tissue healing immediately postsurgery and at the 3rd day, 1 week,
Access this article online
and 2 weeks postoperatively. After the follow‑up period, results were analyzed using appropriate statistical tests.
Website: Results: There was no statistically significant difference observed in the surface epithelialization between both
www.jisponline.com
groups on the 3rd and 7th‑postoperative days, but highly significant differences were observed on the 14th day.
DOI: Conclusion: Within the confines of this pilot study, the outcomes have indicated that gingival wound healing
10.4103/jisp.jisp_226_18 may be improved using LLLT after gingivectomy and gingivoplasty operations.
Quick Response Code: Key words:
Diode laser, gingivectomy, healing index, low‑level laser therapy

INTRODUCTION used in low power.[2] This property of diodes

is widely used for postoperative analgesia, for

L aser dentistry has been at its zenith regarding

research and clinical practice since the
past decade. The first prototype of the laser
temporomandibular joint (TMJ) disturbances, to
improve wound healing, etc. The mechanisms by

was first developed by Maiman in 1960. The
semiconductor diode lasers, also called as
Address for the GaAlAs or the “soft” lasers are compact
correspondence: and inexpensive compared to hard tissue
Dr. Lohith Reddy Mandadi,
lasers which have varied uses in the fields
Department of
Periodontics, Sri Sai of medicine and dentistry.[1] These lasers fall
College of Dental Surgery, under the infrared and red spectrum of light
Kothrepally, Vikarabad, and range from 600 nm to 900 nm. Diode
Hyderabad - 501 101, lasers have multiple applications, and in
Telangana, India. periodontology, it is used for laser bacterial
E‑mail: lohithreddy.
reduction, laser‑assisted periodontal therapy,
mandadi@gmail.com
mucogingival surgeries, etc., All diode lasers
Submission: 05‑04‑2018 have an added property referred to as low‑level
Accepted: 22‑08‑2018 laser therapy (LLLT) or “biostimulation” when
© 2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 53
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Lingamaneni S,
Mandadi LR, Pathakota KR. Assessment of
healing following low-level laser irradiation after
gingivectomy operations using a novel soft tissue
healing index: A randomized, double-blind, split-
mouth clinical pilot study. J Indian Soc Periodontol
2019;23:53-7.
[Downloaded free from http://www.jisponline.com on Monday, July 22, 2019, IP: 117.247.188.33]
Lingamaneni, et al.: Healing following low‑level laser irradiation after gingivectomy operations
which LLLT acts are complex but essentially rely on the fact that
low levels of laser energy results in the stimulation of normal
functions of cells. This result is accomplished by altering the
mitochondrial respiratory chain or by acting on the calcium
channels of the cell membrane.[3‑5] This consequently stimulates
cell proliferation and metabolism.[6,7]
In vitro and in vivo studies demonstrate the ability of this
therapy in stimulating human fibroblasts, immune cells, and
epithelial cells along with superior angiogenesis, growth factor
release, and postoperative pain management which eventually
leads to improved wound healing.[8‑10] Various applications
of LLLT have been tried and tested successfully in cases of
TMJ pain, paresthesia, and periodontal ligament pain during
orthodontic tooth movement, dentinal hypersensitivity and
in periodontal wound healing after various mucogingival and
gingivectomy procedures.[11,12]
Nonetheless, the results obtained after in vivo application
of low‑level lasers remains unclear even to this day. Due to
an insufficient number of controlled clinical trials, not much
is known about the ideal type of laser to be used, mode of
delivery, optimum power output, best energy settings, and the
manner of using these lasers in association with periodontal
surgery.
Therefore, the aim of this randomized controlled clinical pilot
study was to investigate the adjunctive use of LLLT on gingival
healing after gingivectomy procedures.
MATERIALS AND METHODS
This pilot study was designed as a split‑mouth, double‑blinded
study where both the examiner and the patients were blinded.
Study population
This study had a double‑blinded, placebo‑controlled,
and split‑mouth design. The study population comprised
systemically healthy nonsmoking patients with existing gingival
enlargement, who had been referred to the postgraduate clinic
of the Department of Periodontics between June 1, 2015,
and October 15, 2015. Ten patients who fulfilled the study’s
inclusion criteria were selected. Inclusion criteria were
patients aged 18–50 years, systemically healthy patient with no
history of pregnancy/lactation, patients without any history
of periodontal surgery in the past 1 year, and diagnosed as
inflammatory type gingival enlargement. Exclusion criteria
include patients who were not likely to maintain appointment
schedule, previous periodontal surgery within 1 year on study
tooth, pregnant/lactating mothers, and smokers. Gingivectomy
or gingivoplasty operations had been planned in each of these
patients based on his/her customized treatment plan. Since
this is designed as a pilot study, a small sample size is selected.
Each individual signed a detailed informed consent form, and
ethical approval was granted by the Institutional Review Board
for ethical issues (436/SSCDS/IRB‑E/OS/2014).
Surgical protocol and low‑level laser therapy application
In all patients, presurgical preparation consisted of one stage
full‑mouth scaling and root planning using hand and ultrasonic
instruments and oral hygiene instructions.[13] After 4 weeks, the
54 Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019
physiologic gingival contours were reexamined for the need
of gingivectomy/gingivoplasty.
On reevaluation, ten patients (eight female and two male)
who had bulbous or overcontoured gingiva in either of the
jaws with a minimum of six teeth affected were enrolled in
the study.
A simple external bevel gingivectomy procedure was carried
out in these patients with the help of a Kirkland and Orban’s
knives and #15 Bard‑Parker blade. Excised tissue was removed
using curettes, and superficial gingivoplasty was performed
to reestablish suitable esthetic contours. Once, hemostasis was
achieved one half of the surgical site which was assigned to the
test group by coin toss. The test site was irradiated with a diode
laser (810 nm Picasso diode laser, AMD lasers, Indianapolis,
USA) at a power setting of 0.1 W applied in a continuous wave,
noncontact mode for 5 min [Figure 1]. Sham laser application
was imitated for the control sites.
In all the patients, periodontal dressing (Coe‑Pak) was placed.
The dressing was replaced at the 3rd and 7th‑postoperative
visits when laser was reapplied on the test sites [Figures 2
and 3] while the control sites again underwent laser
imitation. On the 14th day, the dressing was removed, and
final application of laser was performed [Figure 4]. To
cope with postoperative pain, the patients were prescribed
ibuprofen and were instructed to take as needed but not
more than thrice per day.
At each appointment, the wound healing was assessed postlaser
application using a healing index Landry et al., [Table 1] which
grades the wound on a scale of 1–5, where 1 indicates very poor
healing and five indicates excellent healing.[14] All gingivectomy
procedures and laser stimulations were performed by one
examiner (S.L.), whereas healing index scores were given by
a different examiner (L. M.).
Table 1: Healing index by Landry et al.
Healing index score Clinical findings
Very poor Tissue color: ≥50% of gingiva red
Response to palpation: Bleeding
Granulation tissue: Present
Incision margin: Not epithelialized, with loss of
epithelium beyond incision margin
Suppuration: Present
Poor Tissue color: ≥50% of gingiva red
Response to palpation: Bleeding
Granulation tissue: Present
Incision margin: Not epithelialized, with
connective tissue exposed
Good Tissue colour: ≥25% and<50% of gingiva red
Response to palpation: No bleeding
Granulation tissue: None
Incision margin: No connective tissue exposed
Very good Tissue colour: <25% of gingiva red
Response to palpation: No bleeding
Granulation tissue: None
Incision margin: No connective tissue exposed
Excellent Tissue color: All tissues pink
Response to palpation: No bleeding
Granulation tissue: None
Incision margin: No connective tissue exposed
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Lingamaneni, et al.: Healing following low‑level laser irradiation after gingivectomy operations
Figure 1: Application of low-level laser therapy in noncontact defocused mode on
test side
Figure 3: Seventh-day postoperative view after application of low-level laser therapy
and two-tone dye
Surface area determination
After application of LLLT on each postoperative visit, the
surgical sites were stained by a plaque‑disclosing agent (2‑Tone
disclosing tablets, Young, USA) to identify the regions of
gingiva in which the epithelialization was incomplete or lacked
complete keratinization [Figures 2 and 4].
The surface area was determined by digitizing the clinical
photographs of the surgical sites and by superimposing
a 1 mm × 1 mm digital grid onto the digitized images to
standardize all the clinical photographs. These digital
images were obtained immediately after the gingivectomy
procedure and on all the following visits after applying the
laser.
The darkly stained bluish areas were deliberated as sites still
going through the process of wound healing and showing
incomplete surface epithelialization. Surface areas of stained
sites in both the test and control groups were compared at the
3rd, 7th, and 14th‑postoperative day and were further evaluated
using appropriate statistical tests.
Statistical analysis
The Mann–Whitney U‑test was used to evaluate the
differences between the test and control groups at each time
Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019 55
Figure 2: Third-day postoperative view after application of low-level laser therapy
and two-tone dye
Figure 4: Fourteenth-day postoperative view after application of low-level laser
therapy and two-tone dye
point. Statistical significance was set at P ≤ 0.05, with <0.001
considered highly significant and  >0.05 considered as not
statistically significant. The Statistical Package for the Social
Sciences version 20.0 for Windows (SPSS Inc., Chicago, IL,
USA) was used for statistical tests.
RESULTS
Ten systemically healthy controls diagnosed with
inflammatory type gingival enlargement with the age of
30–50 years (mean ± standard deviation: 34.5 ± 5.9 years)
comprised the study population in the present study. All
the ten enrolled patients completed the study without any
dropouts in any of the postsurgical visits. Healing took
place uneventfully with no patients reporting any adverse
postoperative complications. The results for the surface area
keratinization are summarized in Table 2 and Graph 1 and the
healing index scores in Table 3 and Graph 2.
On the evaluation of surface keratinization, it was observed that
the stained areas of both groups on the baseline (immediate
postsurgery) and on the 3rd and 7th postoperative days showed
no statistically significant differences. However, on the
14th postoperative day, laser‑activated sites showed significantly
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Lingamaneni, et al.: Healing following low‑level laser irradiation after gingivectomy operations

less surface area that was darkly stained when compared In the present study, the outcomes discovered indicated that laser
to the controls (P = 0.001), demonstrating better surface biostimulation helps stimulate wound healing and improves
epithelialization. Intergroup comparison of the healing index the amount of surface keratinization after gingivectomy and
scores indicates results similar to that of the surface keratinization, gingivoplasty. Healing postsurgery is the interplay of various
wherein there was no statistically significant difference in healing cells of the gingiva such as fibroblasts, keratinocytes, and the
immune cells. Fibroblasts begin laying a new connective tissue
scores at day 0, 3rd postoperative, and 7th postoperative visit. On
beneath the epithelial seal which forms due to the migration
the 14th postoperative day, a significant difference in healing was of cells over the wound surface.[15] Throughout the process
observed among the two groups (P = 0.004). of healing, a series of events occur which are mediated by
cytokines and growth factors that are released by immune cells.
DISCUSSION Literature suggests that LLLT ‑application increases the motility
of epithelial cells and proliferation of fibroblasts which ultimately
The prevailing concept of the use of laser biostimulation as an leads to enhanced wound healing.[8] It has been shown by Tuby
adjuvant to conventional periodontal procedures is that LLLT et al. in an animal study on rats that macrophages and fibroblasts
influences the patient’s postoperative pain perception along show enhanced expression of fibroblast growth factors after
with enhancing the outcome of the treatment and has been low‑level laser application.[16] Laser biostimulation is known to
the area of curiosity to both researchers and clinicians alike. heighten the revascularization process. It is known that higher
rates of revascularization lead to successful healing.[17] An in vitro
However, there seems to be paucity in the available literature in
study showed that gingival fibroblast proliferation was higher
the form of randomized clinical trials assessing the effectiveness when irradiated with low‑level laser.[18]
of LLLT in periodontal procedures.
In spite of the above‑mentioned studies, there are hardly any
Table 2: Intergroup comparison of darkly stained areas clinical trials available to compare the results obtained in the
in % on the 3rd, 7th, and 14th days present study. In 2006, Amorim et al. have stated that wound
Postoperative day Test Control P healing following gingivectomy was significantly promoted by
the application of LLLT (at 685 nm), but contrasting results were
3rd day postoperative 40.187±11.46 49.271±11.30 0.082 (NS)
7th day postoperative 20.986±6.27 25.64±6.24 0.059 (NS) seen in a study by Damante et al. in 2004 where a 670 nm diode
14th day postoperative 1.664±1.47 8.146±4.19 0.001 (S) laser biostimulation failed to improve healing of the gingiva when
P<0.05 is considered statistically significant, with <0.001 considered subjective criteria such as color, contour, and texture were taken
highly significant and >0.05 considered as not statistically significant. into account.[11,12] In a recent study by Ozcelik et al. in which a
S – Significant; NS – Nonsignificant; P – Probability value 588 nm diode laser was used, showed superior wound healing
in sites where LLLT was applied for 7 consecutive days.[19]
Table 3: Intergroup comparison of healing index scores The authors showed that the test sites had significantly better
on the 3rd, 7th, and 14th days epithelialization when compared to control sites on the 3rd, 7th, and
Postoperative day Test Control P
15th‑postoperative days. In the present study, the results clearly
show a significant difference in the levels of surface keratinization
3rd day postoperative 3.3±0.483 2.9±0.875 0.282 (NS)
7th day postoperative 4.1±0.567 3.5±0.971 0.098 (NS)
between both groups on the 14th‑postoperative day (P = 0.001),
14th day postoperative 5±0 4.4±0.516 0.004 (S) while no significant difference was observed on the 3rd and
P<0.05 is considered statistically significant, with <0.001 considered
7th‑postoperative days. This difference may be attributed to the
highly significant and >0.05 considered as not statistically significant. difference in the wavelength and settings of the laser used.
S – Significant; NS – Nonsignificant; P – Probability value
Moreover, the majority of variance seen may be due to the
difference in the study design, i.e., laser application was not
done on the consecutive days.

Graph 1: Intergroup comparison of darkly stained areas in percentage (%) on the

3rd, 7th, and 14th day. Graph 1 illustrates intergroup comparison of darkly stained
areas in percentage (%) on the 3rd, 7th, and 14th day showing that the test group
resulted in better healing by having lower percentage of darkly stained areas.
Darkly stained areas indicate epithelialization was incomplete or lacked complete
keratinization
Graph 2: Intergroup comparison of healing index scores on the 3rd, 7th, and 14th
day. Graph 2, with healing index scores on the Y-axis and day of evaluation on the
X-axis, illustrates better healing with test group compared to the control group

56 Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019

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Lingamaneni, et al.: Healing following low‑level laser irradiation after gingivectomy operations
The novelty of this study when compared with those of the ones
described earlier is the incorporation of a healing index that
was given by Landry et al.[14] This index has been used earlier
in the evaluation of various soft tissue procedures in the fields
of periodontology and oral and maxillofacial surgery. Scoring
criteria of this index are based on five criteria redness, presence
or absence of granulation tissue, bleeding, suppuration, and
epithelialization. The score ranges from 1 to 5, with 1 being
very poor and 5 being excellent healing. Jankovic et al. used
this index to assess the healing of gingival recessions treated
with coronally advanced flaps and connective tissue grafts in
combination with platelet‑rich plasma (PRP) gel.[20] This healing
index was also used to measure soft tissue healing after PRP
placement in extraction sockets and after periodontal, implant
surgery.[21,22]
Like any other work of research, this pilot study also has some
limitations. To begin with, being a pilot study, small sample
size was recruited, this may affect the consistency of the results,
and hence, larger clinical trials are required to assess the true
beneficial nature of LLLT. Available literature was not sufficient
in this regard, especially for the population in question, and so,
a pilot was attempted which can provide valid estimates for
sample size calculation for further studies. Second, this study
was designed as a purely clinical study with no histological
evaluation. Therefore, to assess the effect of LLLT on gingival
healing at a cellular level, further histological studies with
larger sample sizes are required. Furthermore, the application
of customized setting which has not been described earlier in
literature is also a notable and influencing factor in predicting
the outcome of the study.
CONCLUSION
Within the confines of this pilot study, the outcomes have
indicated that gingival wound healing may be improved
using LLLT after gingivectomy and gingivoplasty operations.
Greater insight into the action of LLLT and its effects on the
various cellular structures will largely increase our knowledge
and help us in further sophisticating this treatment modality.
Acknowledgement
We deeply appreciate the constant guidance and support
received from Dr. A. Jaya Kumar sir.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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