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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 51-54

Gingival Depigmentation


Department of Periodontology and Implantology, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Ahmednagar, Maharashtra, India

Date of Submission13-Aug-2020
Date of Decision19-Aug-2020
Date of Acceptance13-Oct-2020
Date of Web Publication25-Feb-2021

Correspondence Address:
Shriram Suresh Kendre
Department of Periodontology and Implantology, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Ahmednagar, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_105_20

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  Abstract 


Gingival hyperpigmentation is the condition where melanin deposition occurs in the suprabasal cell layers of the gingival epithelium. Gingival hyperpigmentation is a multifactorial benign condition which causes esthetic concern to the person. Melanin is a nonhemoglobin-derived pigment formed by melanocytes, which are dendritic cells of neuroectodermal origin in the basal and spinous layers. Melanin is a brown-colored pigment, and it is the result of endogenous pigmentation. The deposition of melanin pigment darkens the color of the gingiva. Many individuals visit the dentist or periodontist to seek the treatment of hyperpigmentation of the gingiva. Gingival pigmentation is usually considered as a genetic factor and affects different races differently. Various treatment modalities are available to remove gingival hyperpigmentation which includes scalpel technique, abrasion using diamond bur, laser therapy, electrosurgery, cryotherapy, chemical cauterization, depigmentation followed by gingival autografts, or platelet-rich fibrin. The present case report describes the case of gingival hyperpigmentation managed by scalpel technique and abrasions by diamond bur which is a simple and a cost-effective technique with satisfactory results.

Keywords: Depigmentation, gingiva, hyperpigmentation, scalpel technique


How to cite this article:
Anarthe RY, Mani AM, Vadvadgi VH, Kendre SS, Sinare SB, Deshmukh SS. Gingival Depigmentation. J Dent Res Rev 2021;8:51-4

How to cite this URL:
Anarthe RY, Mani AM, Vadvadgi VH, Kendre SS, Sinare SB, Deshmukh SS. Gingival Depigmentation. J Dent Res Rev [serial online] 2021 [cited 2021 Apr 21];8:51-4. Available from: https://www.jdrr.org/text.asp?2021/8/1/51/310186




  Introduction Top


The deposition of melanin in the suprabasal layers of the gingiva is responsible for gingival hyperpigmentation. Melanin pigment is brown in color and contributing to the endogenous pigmentation of the gingiva.[1] Melanin is the pigment secreted by melanocytes which are dendritic cells present most commonly in the basal and spinous layer of the epithelium. These melanocytes are neuroectodermal in origin.[2] Melanin pigmentation usually depends on genetic traits and can be physiologic or pathologic.[3] Gingival hyperpigmentation is purely benign, and it is not a medical condition.

It is usually an esthetic concern in patients whose smile line is high or very high. Liebert and Deruelle in 2004 have given the classification for smile lines.[4]

The smile line classification:[4]

  • Class 1: Very high smile line
  • Class 2: High smile line
  • Class 3: Average smile line
  • Class 4: Low smile line.


Gingival hyperpigmentation can be caused by exogenous and endogenous factors. These factors include genetics, endocrine functions, drugs, and heavy metals. However, gingival pigmentation can be increased due to the use of tobacco, i.e., chewing or smoking tobacco. Tobacco stimulates the function of melanocytes and hence the pigmentation increases.[5] Gingival hyperpigmentation affects females more than males, and it is usually present in the anterior labial mucosa.[6] Gingival hyperpigmentation can also be associated with some syndromes such as Laugier–Hunziker syndrome, neurofibromatosis, Peutz–Jeghers syndrome, and hemochromatosis.[7]

Gingival depigmentation involves the removal of superficial layers of the epithelium to reduce the hyperpigmentation. Various treatment modalities are available to reduce or remove hyperpigmentation. These treatment modalities include gingival abrasions, scalpel technique,[8] electrosurgery,[9],[10] free gingival autograft,[11] split-thickness epithelial excision, acellular dermal matrix allograft, neodymium: yttrium, aluminum, and garnet (YAG) lasers,[12] erbium: YAG lasers,[13] cryosurgery,[14] radiosurgery, and the use of chemicals such as alcohols, phenols, and ascorbic acid.

The present case report explains the simple and cost-effective technique of depigmentation, i.e., using scalpel and bur abrasions with satisfactory results.


  Case Report Top


A 24-year-old female patient visited the department of periodontology and implantology, rural dental college of PIMS (DU), Loni, with a chief complaint of black-colored gums. Intraoral examination revealed generalized diffuse hyperpigmented gingiva extending from the right second molar to the left second molar region with Dummett-Gupta Oral Pigmentation Index score 4 [Figure 1]a, [Figure 1]b, [Figure 1]c. The patient had a high smile line. A small tissue tag was present on the maxillary central labial frenum in the midline. Further examination showed that the gingival phenotype was thick and the length of the clinical crown appeared to be decreased. Marginal gingiva was inflamed due to poor oral hygiene of the patient and plaque accumulation. After intraoral clinical examination and blood investigations, the treatment plan was discussed with the patient. After patient consent, the scalpel technique supplemented by bur was planned for the depigmentation.
Figure 1: (a) Preoperative right lateral view. (b) Preoperative left lateral view. (c) Preoperative frontal view of hyperpigmentation. (d) Immediately after Phase I therapy

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Treatment plan

A complete family and medical history was recorded, and routine blood checkup was carried out. The entire treatment plan was explained to the patient, and consent was also obtained from the patient. Considering patients' esthetic concern, surgical treatment was planned after Phase I therapy. A Phase I therapy was completed by patient motivation, education, and thorough scaling and root planing [Figure 1]d. The patient has been instructed to maintain oral hygiene by demonstrating brushing techniques and chemical plaque control. Intraoral evaluation was done after 7 days of Phase I therapy to rule outpatient compliance, plaque control. Oral hygiene maintenance was good with reduced gingival inflammation. Repeat scaling and root planing was performed for further improvement in gingival condition. Gingival depigmentation was planned with scalpel and diamond bur after 3 weeks of Phase I therapy. Surgical crown lengthening by gingivectomy is also accomplished by the scalpel technique and diamond bur.

Procedure

Adequate local anesthesia (lignocaine with adrenaline in the ratio of 1:120,000 by weight) was given to the maxillary anterior and posterior region. After local anesthesia, biological width is assessed and gingivectomy was completed. Gingivectomy was performed from the right second premolar to the left second premolar using blood pressure (BP) handle with blade number 15. Gingival contouring was maintained, and gingival zenith was also corrected [Figure 2].
Figure 2: After gingivectomy of the maxillary arch

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After gingivectomy, the superficial layer of hyperpigmented mucosa is scrapped using BP handle with blade number 15 by positioning the face of blade parallel to long axis of tooth. In this case, as the gingival phenotype was thick, hence a superficial layer of connective tissue is also removed. The remaining hyperpigmented gingiva which was not removed by scalpel was removed using a high-speed handpiece and a diamond bur, and physiologic contours are maintained [Figure 3]a.
Figure 3: (a) De-epithelization of maxillary hyperpigmented tissues. (b) Periodontal dressing (Coe-Pak) given on the maxillary arch. (c) Deepithelization of mandibular hyperpigmented tissues. (d) Periodontal dressing given on the mandibular arch

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During the procedure, to control bleeding, digital pressure was applied to the operated area. For this, a sterile gauze soaked in the local anesthetic solution is used. Once the bleeding is controlled, the operated area was covered with Coe-Pak [Figure 3]b.{Figure 3}

As proper sterilization protocol was maintained, antibiotics were not prescribed to the patient. A combination of analgesic (tablet Zerodol P) was prescribed for 3 days, twice a day. A multivitamin, tablet A to Z, was also prescribed once a day for 7 days for faster healing. The patient was advised to use mouthwash (chlorhexidine gluconate 0.2%) twice a day for 15 days.

The patient was recalled after 1 week for follow-up. The patient did not complain about any pain or discomfort. Healing was uneventful, and the results obtained were satisfactory for the maxillary arch. The same surgical depigmentation procedure was repeated for the mandibular arch [Figure 3]c.

Periodontal dressing (Coe-Pak) was given after the completion of the procedure [Figure 3]d. The same medications were prescribed. The patient was recalled after 1 week for follow-up.

Follow-up report after 7 days showed uneventful healing with no discomfort. Gingival hyperpigmentation was completely disappeared [Figure 4]a, [Figure 4]b, [Figure 4]c.
Figure 4: Follow-up after 1 week of treatment. (a) Frontal view. (b) Left lateral view. (c) Right lateral view

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  Discussion Top


Melanin pigmentation is present in all parts of the body. The distribution of melanin pigmentation is different in different parts of the body. Different races are affected differently with melanin pigmentation. Melanin pigmentation is seen more in dark skinned individuals than in fair persons.[15] Melanin pigmentation also decides the color of the gingiva. There are various factors which decide the color of the gingiva which includes degree of keratinization, blood supply of the gingiva, thickness, and melanin pigmentation of the gingiva.[16] There was no significant difference observed in pigmentation in females and males.[17]

Melanin pigmentation occurs due to the deposition of melanin by active melanocytes produced by the melanoblastic activity. These melanocytes are present predominantly in basal and spinous layers of the epithelium. Melanin pigmentation in the gingiva can also be increased due to smoking and the use of tobacco. Tobacco smoking causes irritation to the epithelium, this in turn activates melanocytes and ultimately these melanocytes deposit more melanin pigment.[5]

In today's world, esthetics are an important concern of all the individuals. Gingival hyperpigmentation is a problem, particularly for those patients whose smile line is high or very high. Depigmentation is the only available treatment modality to treat hyperpigmentation.

Various treatment options are available to treat gingival hyperpigmentation such as de-epithelization by scalpel, diamond bur abrasions, lasers, cryotherapy, and chemical cauterization.[18] Of all these treatment options, scalpel technique in combination with diamond bur abrasions is the most simple and affordable technique. Scalpel technique have some drawbacks such as intraoperative and postoperative bleeding , time consuming procedure, post-operative pain and discomfort. Other treatment options involve costly equipment and particular skills to perform the treatment.

Re-pigmentation occurs due to the migration of melanocytes to superficial epithelial layers. It is a clinical reappearance of melanin pigment occurred sometimes after depigmentation. Re-pigmentation is a common problem which occurs in every single case. The re-pigmentation can occur between 24 days and 8 years.[19] Studies suggest that chances of re-pigmentation after scalpel technique are 21.4% and that of laser therapy are 22.8%.[20],[21] Hence, considering these things, scalpel technique in combination with diamond bur abrasions was used in this case.


  Conclusion Top


The surgical removal of gingival hyperpigmentation using scalpels is one of the simplest and popular techniques to be used. This treatment involves surgical removal of superficial layers of gingival epithelium along with a thin layer of the underlying connective tissue. Melanin pigmentation is not present in newly formed epithelium. In this particular case, the scalpel method of depigmentation showed better results from both clinical and patient's points of view. The area healed completely in 10 days with normal appearance of the gingiva. Esthetics of the patient upon smile are improved to a considerable extent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dummett CO, Barens G. Oromucosal pigmentation: An updated literary review. J Periodontol 1971;42:726-36.  Back to cited text no. 1
    
2.
Ciçek Y, Ertaş U. The normal and pathological pigmentation of oral mucous membrane: A review. J Contemp Dent Pract 2003;4:76-86.  Back to cited text no. 2
    
3.
Verma S, Gohil M, Rathwa V. Gingival depigmentation. Indian J Clin Practice 2013;23:801-3.  Back to cited text no. 3
    
4.
Liebart ME, Deruelle CF, Santini A, Dillier FL, Corti VM. Smile line andperiodontium visibility. Perio 2004;1:17-25.  Back to cited text no. 4
    
5.
Lee KM, Lee DY, Shin SI, Kwon YH, Chung JH, Herr Y. A comparison of different gingival depigmentation techniques: Ablation by erbium: yttrium-aluminum-garnet laser and abrasion by rotary instruments. J Periodontal Implant Sci 2011;41:201-7.  Back to cited text no. 5
    
6.
Dummett CO, Gupta OP. Estimating the epidemiology of oral pigmentation. J Natl Med Assoc 1964;56:419-20.  Back to cited text no. 6
    
7.
Shafer WG, Hine MK, Levy BM. Text Book of Oral Pathology. Philadelphia: WB Saunders co.; 1984. p. 89-136.  Back to cited text no. 7
    
8.
Almas K, Sadiq W. Surgical treatment of melanin-pigmented gingiva: An esthetic approach. Indian J Dent Res 2002;13:70-3.  Back to cited text no. 8
    
9.
Oringer MJ, editor. Electrosurgery in Dentistry. 2nd ed. Philadelphia: W.B. Saunders Co.; 1975.  Back to cited text no. 9
    
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Gnanaesekhar JD, Al-Duwairi YS. Electrosurgery in dentistry. Quintessence International (Berlin) 1998;29:649-54.  Back to cited text no. 10
    
11.
Tamizi M, Taheri M. Treatment of severe physiologic gingival depigmentation with free gingival autograft. Quint Int 1996;27:555-8.  Back to cited text no. 11
    
12.
Atsawasuwan P, Greethong K, Nimmanon V. Treatment of gingival hyperpigmentation for esthetic purposes by Nd: YAG laser: Report of 4 cases. J Periodontol 2000;71:315-21.  Back to cited text no. 12
    
13.
Tal H, Oegiesser D, Tal M. Gingival depigmentation by erbium: YAG laser: Clinical observations and patient responses. J Periodontol 2003;74:1660-7.  Back to cited text no. 13
    
14.
Yeh CJ. Cryosurgical management of melanin pigmented gingival. Oral Surg Oral Med 1998;86:660-3.  Back to cited text no. 14
    
15.
Szabó G, Gerald AB, Pathak MA, Fitzpatrick TB. Racial differences in the fate of melanosomes in human epidermis. Nature 1969;222:1081-2.  Back to cited text no. 15
    
16.
Steigmann S. The relationship between physiologic pigmentation of the skin and oral mucosa in Yemenite Jews. Oral Surg Oral Med Oral Pathol 1965;19:32-8.  Back to cited text no. 16
    
17.
Gondak RO, da Silva-Jorge R, Jorge J, Lopes MA, Vargas PA. Oral pigmented lesions: Clinicopathologic features and review of the literature. Med Oral Patol Oral Cir Bucal 2012;17:e919-24.  Back to cited text no. 17
    
18.
Sharath KS, Shah R, Thomas B, Madani SM, Shetty S. Gingival depigmentation: Case series for four different techniques. NUJHS 2013;3:132-6.  Back to cited text no. 18
    
19.
Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.  Back to cited text no. 19
    
20.
Hegde R, Padhye A, Sumanth S, Jain AS, Thukral N. Comparison of surgical stripping; erbium-doped: Yttrium, aluminum, and garnet laser; and carbon dioxide laser techniques for gingival depigmentation: A clinical and histologic study. J Periodontol 2013;84:738-48.  Back to cited text no. 20
    
21.
Dummet CO, Bolden TE. Post surgical repigmentation of the gingival. Oral Surg Oral Med Oral Path 1963;16:353.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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