Laser Depigmentation

Case Study with the Picasso Lite Laser by Tammy Maahs,

RDH, BSDH, EP and Tammy Johns, RDH, BSDH, EP

Smokers Melanosis
Smoker's melanosis presents as a brown to black pigmentation of the oral
tissues.

Can be seen in attached and unattached gingiva, buccal mucosa, and palate.
While there are other types of melanin pigment (considered normal) in
some individuals gingiva, smokers melanosis is not a genetically caused
melanin pigmentation.

Case Report
My sister noticed a brown discoloration on her marginal and papillary
gingiva between #6 and 7 about 3-4 years ago. At the time, she said she
does hold her cigarette here when she smokes.

She is a light smoker, 1-2 cigarettes a day.

Her smile line is above her teeth and this shows.
Gingiva is otherwise healthy.

Christmas Mother/Daughter Picture

I noticed at Christmas time that this appeared a bit darker and had the idea that I
should do some research on depigmentation of oral lesions with a diode laser.
Despite discontinuing holding her cigarette in this area, the lesion remained. I
consulted with my friend and colleague, and we agreed this might be fun to
explore!

Picasso Lite Diode Laser

It made perfect sense to us that this would be an applicable use for the diode laser (soft
tissue laser).
Diode wavelengths are absorbed by pigmented structures, such as hemoglobin and
melanin, and work well in soft tissues. The light energy is transferred to heat, resulting in an
instantaneous tissue reaction of warming, coagulation, and cell vaporization. This
instantaneous reaction is termed ablation and results in minimal tissue bleeding. With the
diode laser, soft tissue procedures can often be performed with slight discomfort requiring
only minimal anesthesia.
~Dimensions of Dental Hygiene, Laser Therapy Basics, Tolle and Sirois, January 2011; 9(1): 50, 52-53.
http://www.dimensionsofdentalhygiene.com/ddhnoright.aspx?id=10224&term=laser%20therapy%20basics

Pre-op Photographs

After careful research and planning; consulting with a dentist colleague in

California for a specific protocol, and obtaining consent from our patient we
decided to do this procedure!

Low Level Laser Therapy (LLLT)

With the patient anesthetized with cartridge of articaine, we started with the typical
protocol for LLLT; which is typically used for aphthous ulcers, oral herpetic lesions,
chemotherapy induced mucositis, and lichen planus lesions. This is a non-ablative technique
with a non-initiated tip. This brings blood flow to the areas without causing trauma.

Used a 300 micron tip for small lesions (5 mm)

Set Picasso Lite for Comfort Mode at 1.2 watts pulsed and then increased up to .2 watts with each
cycle for a maximum of 1.6 watts
Began with the tip defocused from the lesion (5-8 mm).

Advanced slowly towards the area, stopping 2-3mm away.

Used a continual, painting motion moving from the peripheral to the center for 30-45 seconds.
Allowed tissue to cool for 15-20 seconds in between cycles.
Evaluated the temperature of the tissue with palpation.
The maximum total of laser energy was less than 2 minutes

Laser Ablation for Depigmentation

Set the Picasso Lite laser at 1.5 watts continuous, and initiated the tip.
Repeatedly touched the tip to the lesion with a blotting action on the
marginal area, covering the entire area of the lesion except for the papilla.

Set to pulsed for the papilla after noting some slight charring of the tissue.
Allowed tissue to cool.
Post operative instructions included warm salt water and applying Vitamin E
oil.

One Day Post Operative

Second Treatment LLLT (without local anesthesia)

LLLT and LBR (Laser Bacterial Reduction)

In addition to the LLLT, Laser Bacterial Reduction was performed
subgingivally in the sulcus/papilla area #6-7. LBR also uses a non-initiated
tip at 1.5 watts pulsed (Comfort Mode).

The tip is placed 0.5 mm into the sulcus. A sweeping, horizontal motion is
used for just a few seconds to reduce oral bacterial levels.

The patient experienced no discomfort with this procedure.

Day 3 Post-Operative

Day 4 Post-Operative

Day 5 Post-Operative

Day 6 Post-Operative

One Week Post-Operative

One Week + One Day Post-Operative

Conclusion
The patient was pleased with this minor cosmetic procedure and consented
to sharing the photographs.

As we always say, it is all about discovery. Research shows this procedure is

another practical application of the diode laser. We are grateful to our
patient for consenting to us performing the procedure!

Credits!
Special thanks to Tammy Johns, RDH, BSDH, EP; owner of Absolute Dental
Hygiene where this procedure was performed. She also performed the
procedure! http://www.absolutedentalhygienellc.com/

AMD Lasers http://www.amdlasers.com/

Dr. David Hornbrook, D.D.S., San Diego, CA https://hornbrook.com/