ISSN: 18121217

Clinical Comparison between Diode Laser

and Scalpel Incisions in Oral Soft Tissue
Biopsy
Wael S Shalawe
BDS, FIBMS MF (Lec.)

Department Oral and Maxillofacial surgery

College of Dentistry, University of Mosul

Zaid A Ibrahim
BDS, MSc (Asst Lec.)
Ali D Sulaiman
BDS, MSc (Asst Lec.)

p
p

ABSTRACT
Aims of the study: To compare the new diode laser (1064nm) incision with conventional blade incision wounds after oral soft tissue biopsy in terms of haemostasis, local anesthetic required, duration of
incision and post operative pain. Materials and Methods: This study was conducted in the Oral and
Maxillofacial Surgery Department at College of Dentistry/University of Mosul and Oral and Maxillofacial Surgery Department in Al-Salam Teaching Hospital between February 2010 and May 2010.
Thirty patients were enrolled and divided into two groups, each consisted of fifteen patients. The first
group included fifteen patients requiring biopsy (based on their indications for biopsy) in the oral cavity, where the incision was done using surgical blade no.15. The second one included fifteen patients
who needed biopsy in the oral cavity (based on their indications for biopsy), here the incision was
made by using diode laser (FOXTM, A.R.C. laser, Germany) wavelength 1064nm with output power
(3.5Watt) CW in contact with the tip of bare fiber (200micron). All biopsies in the two groups were
excisional and done under local anesthesia using infiltration technique. Results: In comparison between the two groups: the amount of local anesthetic required in the second group (diode laser wound
group 0.73 ml) was less than that required by the first group (blade incision wound group 1.6 ml) and
showed statistically high significance at p value < 0.05. The mean of the difference in the weight of the
gauze before and after the operation in the second group(0.16 gm) was less than the difference in the
weight of the gauze in the first group(0.96 gm) which showed statistically high significance at p value
<0.05. The mean of the duration for incision was statistically not significant between the two groups
and the mean of pain score at the first post-operative day was statistically significant in the second
group in comparison to the first group but there was no statistical difference in the pain score level at
the third postoperative day between the two groups. Conclusion: The use of Diode (1064nm) laser to
perform oral biopsy has several advantages over the blade incisions wound including less amount of
local anesthesia required, enhanced haemostasis (suturing after surgery was not necessary) , minimal

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www.rafidaindentj.net

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Shalawe WS, Ibrahim ZA, Sulaiman AD

postoperative pain.
Key words: Diode laser, Scalpel wound, Oral soft tissue biopsy.
Shalawe WS, Ibrahim ZA, Sulaiman AD. Clinical Comparison between Diode Laser and Scalpel Incisions in Oral Soft Tissue Biopsy. AlRafidain Dent J. 2012; 12(2): 337-343.
Received: 25/4/2011
Sent to Referees: 27/4/2011
Accepted for Publication:16/6/2011

INTRODUCTION
Three methods for cutting oral soft tissues are used commonly in dentistry,
namely blade, electro surgery and laser,
each of these methods works.(1) However,
they are different from the standpoints of
hemostasis, healing time, cost of instruments, width of the cut, anesthetic required and disagreeable characteristics,
such as smoke production, the odor of
burning flesh and undesirable taste.(2) Steel
scalpel and laser systems are widely utilized as effective tools in soft-tissue surgical procedure. A scalpel is commonly
employed because of its ease of use, accuracy, and minimal damage to tissues.
Scalpels do not provide good hemostasis,
which is important in highly perfused tissues such as in the oral cavity. (3)Dentists
also know that there are desirable aspects
of using a scalpel for soft-tissue cutting,
including ease of use, low cost and relatively fast and uneventful healing.(2)
Laser light is monochromatic and has specific wave length. Laser light is coherent
and organized, directional, strong and
concentrated. It is not like a typical flashlight, which releases light in many directions. There are many different types of
lasers e.g. Er:YAG, Co2, Nd:YAG and
diode laser. The medium of light transmission can be solid, gas, liquid or semiconductor like diode laser. (4) Researches and
observations in previously referenced articles about laser use suggest the following
soft-tissue uses for laser: gingivectomy;
gingivoplasty, frenectomy,(5) biopsy, operculectomy, leukoplakia, elimination of
open pockets reduction of maxillary tuberosity, vestibuloplasty and uncovering
implants,(6-9) the advantages of lasers for
soft tissue cutting are their use requires
minimal or no anesthetic; they do not
harm dental hard tissues; their judicious
use does not injure the dental pulp; because of low or no heat production, they
can be used around dental implants; they
are antimicrobial; they remove endotoxins

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from root surfaces. (10,11) The disadvantages of lasers for soft-tissue cutting include :
the cost of laser is significantly higher
than that of conventional scalpel , because
of the potential hazard of laser light, laser
use requires a learning period and strict
precautions, laser can cause eye damage,
so protective glasses( protective eyes
Google) are required during its use, there
is a burning flesh odor and some techniques are time consuming.(12,13)

MATERIALS AND METHODS

This study was conducted at the Oral
and Maxillofacial Surgery Department in
the College of Dentistry/ University of
Mosul and Oral and Maxillofacial Surgery
Department in Al-Salam Teaching Hospital between February 2010 and May 2010.
Thirty patients were enrolled and divided
into two groups, each consisted of fifteen
patients, the first group included fifteen
patients requiring excisional biopsy (based
on their clinical indications for biopsy) in
the oral cavity, and the incision was performed using surgical blade no.15 (Martin,
Germany). The second group included
fifteen patients who needed excisional
biopsy in the oral cavity ( based on their
indications for biopsy), in this group, the
incision made by using diode laser
(FOXTM, A.R.C. laser, Germany) wavelength of 1064nm with output power(3.5Watt) continuous wave in contact
with the tip of bare fiber (200micron), using protective eyes glasses( supplied with
the laser device, Fox Laser, A,R,C laser)
for both the operators and the patients and
wooden tongue spatula for tissue reflection to minimize hazardous reflection of
laser radiation
All the biopsies in the two groups were
excised under local anesthesia ( Lidocaine
HCL 2% with 1:80,000 Epinephrine,
Houns Co.,ltd. Korea) using infiltration
technique, a specific data form was made
for each patient in the two groups and

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Diode laser (1064nm) and scalpel incision in oral soft tissue biopsy

included personal information, medical

history, site and size of the lesion in (mm)
by vernier gauge (Dentaurum-Germany),
color and consistency of the lesion, ,
amount of local anesthesia administered
(ml) , weight of the gauze in (milligram)
before excision of the lesion and after excision of the lesion that had been measured using the sensitive electronic balance
(Todoscan, calibration scale, China),(14,15)
operation time (duration of surgery) from
incision to last stich which was measured
by (CASIO illuminator count down timer,
telememo 30, Japan), visual analog scale

for post-operative pain, the severity of

pain was assessed using scale of 0 (no
pain) to 10 (un bearable pain) score recorded first and third days post operatively
(16-20)
In the first group, the wound was
sutured by 3/0 black silk suture (Silk
Braided, Jiannan China) and the suture
removed a week after the operation, while
in the second group simple dressing
(sterile gauze) was placed to cover the
wound (Figure 1).

Figure(1) intra oral photograph show excisional biopsy for a soft tissue lesion at the hard palate by diode laser
Patients were also given appropriate
instructions and recommendations regarding the postoperative recovery period.
Postoperative medications were given to
both groups which include a 5-day course
of Amoxicillin 250mg orally three times a
day, 0.2% Chlorhexidine gluconate
mouthwash, Paracetamol 500mg orally
three times a day The data analyzed statistically using T test- independent sample
test to compare the result of parameter
changes between the 2 groups and paired
sample test to study the results of parameter changes in each group separately in
SPSS (statistical package for social
science) V.13.0 program, Pentium 4.

RESULTS
The first group comprised eight females (53.3%) and seven males (46.7%)
with age range between (20-55) years and
mean age of (35.67) years, The second

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group comprised ten male patients

(66.7%) and five female patients (33.3%)
and age range between (7-50) years with
mean age of (30.07) years
In the first group (scalpel wound
group) the mean of the lesion size that had
been excised was (1.86 mm). In regard to
the amount of local anesthetic that had
been administered to perform the biopsy,
the mean was (1.6 ml). The mean duration
of surgery in this group was (8.4 minutes),
the mean of the pain score at the first day
postoperatively by using visual analog
scale was (6.93) , while it was (2.13) for
the third day. The mean of the difference
in the weight of gauze before and after the
operation was (0.96 gm). The four mentioned parameters in this group were illustrated in Figure (2) Table (1).

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Shalawe WS, Ibrahim ZA, Sulaiman AD

Figure (2): The results of parameters changes in scalpel wound group.

Table (1): The mean and the standard deviation of the parameters in the laser and scalpel
wound groups.
Group

Laser
wound
group

Scalpel
wound
group

Maximum
50
1.50
1.80

Mean

+SD

15
15
15

Minimum
7
0.50
0.50

30.07
0.9433
0.7353

11.695
0.32889
0.45294

15

0.00

0.80

0.1667

0.20931

15
15

2
3

15
7

6.00
5.20

3.665
1.146

15

1.33

0.976

15
15
15

20
0.50
0.75

55
3.00
2.50

35.67
1.8667
1.6000

10.033
0.76687
0.63415

15

0.16

1.60

0.9680

0.36054

15
15

5
6

13
8

8.40
6.93

2.613
0.799

15

2.13

1.060

Parameter

No.

Age
Size of the lesion
Amount of Lcal anesthesia
Difference in weight of
gauze
Duration of incision
Pain/ first postoperative day
Pain/ third postoperative
day
Age
Size of the lesion
Amount of Local anesthesia
Difference in weight of
gauze
Duration of incision
Pain/ first postoperative day
Pain/ third postoperative
day

In the second group (diode laser

wound group), the mean of the size of the
lesion was (0.94 mm). In regard to the
amount of local anesthetic that had been
administered to perform the biopsy the
mean was (0.73ml). The mean for duration
of the surgery in this group was (6.0 minutes), the mean of the pain score at the

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first was (5.20) while in the third day

postoperatively was (1.33) by using visual
analog scale. The mean of the difference
in the weight of the gauze in this group
was (0.16 gm). The mean for these parameters in this group was shown in Figure
(3) Table (1).

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Diode laser (1064nm) and scalpel incision in oral soft tissue biopsy

Figure (3): The results of parameters changes in diode laser wound group.

In comparison between the two groups

: the amount of local anesthetic required in
the second group ( diode laser wound
group 0.73 ml) was less than that required
by the first group (scalpel wound group
1.6 ml) and statistically highly significant
difference was observed at p value <
0.05,the mean of the difference in the
weight of the gauze before and after the
operation in the second group (0.16 gm)
was less than the difference in the weight
of the gauze in the first group (0.96 gm)
which was statistically highly significant

at p value <0.05, the mean of the time for

incision in the diode laser group was less
than the mean of scalpel incision time but
statistically not significant at p value
<0.05), the mean of pain score at the first
post operative day was statistically significant in the diode laser wound group in
comparison to the scalpel wound group
but there was no statistical difference in
the pain score at the third postoperative
day between the two groups as shown in
Table (2).

Table (2): Independent Sample Test show the P value and the significant parameters changes
between the two groups

Parameter
Local anesthesia
Difference in
weight of gauze
Duration of the
incision
Pain/day 1
Pain/day 3
DISCUSSION
Laser radiant energy interacts with the
tissue in several ways: reflection, transmission, scattering and absorption. When
the tissue is incidentally heated by laser
beam to temperatures over 600C, it undergoes coagulation.(21) This coagulation phenomena are the basis of most surgical ap-

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p-value
0.000

Significant

0.000

Significant

0.648

Not significant

0.000
0.740

Significant
Not significant

Significance

plications of laser and as a result of photocoagulation, protein, enzymes, cytokines

and other bioactive molecules are heated
to temperatures over 600C, the result being instant denaturation. Alteration in the
molecular structures of tissue collagen
from trihelical to randomly disturbed helical polymers and coils after laser beam

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Shalawe WS, Ibrahim ZA, Sulaiman AD

radiation is the basic physical event which

will lead to shrinkage of the collagen fibers after photocoagulation, the lased tissue constricts against the proximal vasculature and the vessels shrink as a result of
the collagen in their walls which result in
enhanced hemostasis. Laser damage to
erythrocytes attracts a population of platelets which encourage intraluminal thrombosis,(21) further decrease in the blood loss
and this explains why the laser wound
group had minimal blood loss in comparison to the scalpel wound group and this is
especially important in our study as we
used diode laser device with a wave length
1064 nm which is similar to the wave
length of Nd-YAG laser devices with the
advantage that the diode laser has continuous steady mode with constant energy
delivered to the tissue so more control
output power than pulsed mode Nd-YAG
laser devices with little risk of damaging
the adjacent structures ( tooth structures ,
nerves and vessels). With the 1064 nm
wave length in diode laser, deeper coagulation tracts (1.5 mm) are obtained by selective photocoagulation of tissue containing so called target chromophore such as
water , melanin and reduced and oxygenated hemoglobin.(21) The small, portable
size of diode laser unit is of beneficial effect to the general practitioner who is not
able to move easily from office to office
the big size laser unit like Nd-YAG laser
unit. In addition, the diode laser unit is less
expensive than the Nd-YAG laser device
(22)
. The extraordinary rapid cell vaporization with loss of intracellular fluid, chemical mediators (cytokines) and denaturation
of intracellular substance and protein is
posited to result in a markedly less intense
local inflammatory response and consequently less local pain , edema and cicatrix
formation,(23,24) and this may explain the
need for small amount of local anesthesia
required to perform laser surgery in comparison to the scalpel incision.(25) Frame
and Fisher describe the pattern of cell destruction that occurs without the usual release of cytokines characteristic of acute
inflammation. They also described how
the thin layer of denatured collagen on the
surface of the lased tissue acts as a relatively impermeable membrane or impermeable dressing immediately after lasing

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,Thus reducing the amount of tissue irritation from physical and biochemical agents
in the intraoral environment and this may
explain why the lased tissue exhibit minimal postoperative pain.(26,27) Basu and
colleagues made several observations that
contradicted the earlier observations on
myofibroblasts and sealed nerve endings
in the laser wound and this later finding
has been used to explain the relative lack
of pain after laser surgery.(28) The time to
perform laser incision is some-times less
than the time required to perform scalpel
incision but this not always true as laser
may in some cases prolong the operation
time rather than shorten it and the time
may be affected by the skill of the operator
,the equipment available and the clinical
entity of the lesion.(29)

CONCLUSION
The use of laser to perform oral biopsy
has several advantages over the scalpel
wound including less amount of local
anesthesia required, enhanced haemeostasis (suturing after surgery was not necessary which is economical advantages),
minimal postoperative pain, edema with
less inflammatory response.

REFERENCES
1. Ramirez A. M., Silvestre F. J., Simo J.
M. Oral biopsy in dental practice. Med
Oral Patol Oral Cir Bucal. 2007;
12(7):504-10.
2. Christensen G. J. Soft-tissue cutting
with laser versus electrosurgery. J Am
Dent Assoc. 2008;139: 981-982.
3. DArcangelo C., Prosperi G. D., Conte
E. A preliminary study of healing of
diode laser versus scalpel incisions in
rat oral tissue: a comparison of clinical,
histological, and immunohistochemical
results. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;
103:764-73.
4. Coluzzi DJ. Lasers and soft tissue curettage: an update. Compend Contin
Educ Dent, 2002; 23(11A):1104-1111.
5. The Research, Science and Therapy
Committee of the American Academy
of Periodontology: Lasers in Periodontics. J Periodontol 2002;73:1231-1239.
6. Ishii J., Fujita K., Komori T. Laser sur-

342

Diode laser (1064nm) and scalpel incision in oral soft tissue biopsy

gery as a treatment for oral leukoplakia: Oral Oncology 2003; 39 :759769

7. Deppe H., Horch H. Current status of
laser applications in oral and craniomaxillofacial. Medical Laser Application 2007; 22:3942.
8. Okudera H. Evaluation of laser surgery
for implantation. International Congress Series. 2003; 1248: 413 414.
9. Deppe H., Horch H. Laser applications
in oral surgery and implant dentistry.
Lasers Med Sci. 2007; 22:217221.
10. Pick RM, Colvard MD. Current status
of lasers in soft tissue dental surgery. J
Periodontal 1993; 64(7):589-602.
11. Sulieman M. An overview of the use of
lasers in general dental practice: two
Laser wavelengths, soft and hard tissue
clinical applications. Dent Update
2005; 32(5):286-288, 291-294, 296.
12. Parker S. Lasers and soft tissue:
loosesoft tissue surgery. Br Dent J
2007; 202(4): 185-191.
13. Sarver DM. Use of the 810 nm diode
laser: soft tissue management and orthodontic applications of innovative
technology. Pract Proced Aesthet Dent
2006; 18(9 suppl):7-13.
14. Fioole B. , van der Bilt J.D.W, Elias
S.G., de Hoog J., Borel Rinkes I.H.M.
Precoagulation minimizes blood loss
during standardized hepatic resection in
an experimental model. Br J of Surg
2005;92:1409-16.
15. Eipe N., Ponniah M. Perioperative
blood loss assesmsnt-how accurate?
Indian J Anesth. 2006;50(1):35-38.
16. Crichton N. Information Point: Visual
Analogue Scale (VAS). J of Clinical
Nursing, 2001; 10, 697706.
17. Yuasa H., Sugiura M. Clinical postoperative findings after removal of impacted mandibular third molars: prediction of postoperative facial swelling
and pain based on preoperative variables. Br J of Oral and Maxillofac.
Surg. 2004; 42, 209214.
18. Pearrocha M., Sanchis M., Sez U.,
Gay C., and Bagn J. V.,Oral hygiene
and postoperative pain after mandibular
third molar surgery, Oral Surg. Oral
Med. Oral Patho.l Oral Radiol. Endod.2001; 92:260-4.
19. Moore P. A., Brar P., Smiga E. R., and
Costello B. J. Preemptive rofecoxib

343

and dexamethasone for prevention of

pain and trismus following third molar
surgery, Oral Surg. Oral Med. Oral
Pathol. Oral Radiol. Endod. 2005;
99:E1-7.
20. Amarillas-Escobar E. D., ToranzoFernndez J. M., Martnez-Rider R.,
Use of therapeutic laser after surgical
removal of impacted lower third molar.
J Oral Maxillofac Surg. 2010; 68:319324.
21. Guy A, CharlesC. : Laser applications
in oral and maxillofacial surgery. chapter 2 photobiology of laser on oral and
maxillofacial surgery. 1997; Pp 32-38.
22. George E, Georg H: application of diode laser in oral and maxillofacial surgical procedures. Preliminary clinical
observation. Der Einsatz des Nd:YAGLasers bei der hereditaren hamorrhagischen Teleangiektasie.1997; 48:
1613-1618.
23. Strong MS, Jako GJ, Polanyi T, et al :
laser surgery in the aero digestive tract.
Am J Surg 1973,126:529-533.
24. Tuffin JR, Carruth JAS. The carbon
dioxide laser. Br Dent J 1980;149:255258,.
25. Shuller DE: Use of the laser in the oral
cavity. Otolaryngology. Clin North
Am. 1990; 28:287.
26. Fisher SE, Fram JW, Brown RM: A
comparative histological study of
wound healing following CO2 laser
and conventional surgical excision of
canine buccal mucosa. Arch Oral Bio.
1983; 28:287-291.
27. Fisher SE, Fram JW. The effects of
CO2 surgical laser on oral tissue. Br J
Oral and Maxillofac Surg.1984;
22:414-425.
28. Basu MF, Fram JW RhysEvans PH:
wound healing following partial glossectomy using CO2 laser, diathermy
and scalpel. A histological study in
rats. J laryngol Otol 1988;102:322.
29. Guy A, Charles C: Laser applications
in oral and maxillofacial surgery. chapter 7, laser management of discrete lesions.1997; Pp:115-116.

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