Scalpel versus electrosurgery: Comparison of gingival perfusion status using ultrasound Doppler flowmetry
A 22-year-old female patient reported, with a chief complaint of small teeth and black gums. On examination, gingiva appeared hyperpigmented (blackish purple in color) and the marginal gingiva was enlarged thick and fibrotic []. Complete medical history and blood investigation was carried out to rule out any systemic condition. A diagnosis of delayed apical migration of the gingiva with hyperpigmentation was made. Treatment plan included gingivoplasty and depigmentation under local anesthesia. The surgical procedure was explained to patient and informed consent was obtained.\nThe procedure was planned to be performed using a scalpel in lower anterior and electrosurgery (surgical techniques performed using controlled, high frequency electrical currents i.e., 1.5-7.5 million cycles/s) in upper anterior to determine the healing pattern with these two different techniques. Gingival vascularity was determined using soft-tissue USG with spectral Doppler study.\nUSG studies were performed using a high definition USG unit with 2D, 3D and color Doppler facilities []. For gingival study, intracavitary convex transducer with 9-5 MHz capacity was used since this probe facilitated adequate and satisfactory intra-oral accessibility. For the study of anterior segment gingiva, a cheek retractor was used and a water filled glove finger was placed over the gingiva. The transducer was applied over the water filled glove finger in a coronal plane with interspersed ultrasonic gel for proper contact. The water filled glove finger served as a water path for the sound waves and provided better clarity and detail. USG settings were adjusted for 4.5 cm depth, which would be adequate for covering the depth of the water path and the gingiva.\nIn Doppler settings, sound waves pass through blood vessels and get scattered (reflected) by moving red blood cells. Color Doppler settings delineate the color coded blood vessels as rounded or oval dots or linear or cylindrical structures. The number of color coded structures will indicate the number of blood vessels in the region under study. Thus, color Doppler gives information about the amount of vascularity in the region of interest. For spectral Doppler studies, pulse wave Doppler cursor is focused over the blood vessels, which are depicted as color coded blood vessels and the update key is pressed. This enables delineation of flow pattern in the gingival graphically. Recording the flow pattern in the form of a graph (spectral Doppler) allows measurement of velocity of flow both in peak systolic velocity (PSV) and end diastolic velocity phases. These values are displayed on the monitor once the tracing over the graph is marked by auto or manual mode. This helps to measure the velocity of flow.\nBy the placement of the transducer in a sagittal plane over both upper (13-23 region) and lower (33-43 region) segments, study of the gingiva in both arches is possible in the same field.\nPre-operatively the spectral Doppler study was performed in both upper [] and lower anterior gingival segment []. The PSV was determined.\nAfter administration of local anesthesia, gingivoplasty and depigmentation (the entire pigmented epithelium along with a thin layer of connective tissue was removed) was performed using No. 15 blade (scalpel) in lower anterior segment [Figures and ]. Hemostasis was obtained using sterile gauze and applying direct pressure on the surgical wound.\nIn relation to upper anterior segment, the procedure was performed using the electrosurgery. Using a loop electrode, the entire pigmented epithelium along with a thin layer of connective tissue was removed by a planning motion from the mucogingival junction to the marginal gingiva [Figures and ]. The region was irrigated with saline frequently to dissipate the heat generated by the electrode. Care was taken that the electrode did not touch the bone. Compared with the surgical technique carried out by using a scalpel, the electrosurgery procedure produced less bleeding, which offered better visibility. Patient was placed on analgesics and 0.2% chlorhexidine digluconate mouth rinse twice daily for 2 weeks.\nPatient was recalled on 7th, 15th and 30th day following surgery. Both clinical examination [Figure -] and spectral Doppler studies [Figure -] were performed in upper and lower anterior region to compare the perfusion state.