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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 1  |  Page : 50-55

Treatment of gingival hyperpigmentation using different techniques


1 Department of Oral Medicine and Periodontology, Faculty of Dentistry, Suez Canal University, Ismailia, Egypt; Department of Periodontics, College of Dentistry, Gulf Medical University, Ajman, UAE
2 Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha, Saudi Arabia
3 Department of Oral Medicine and Radiology, College of Dentistry, Gulf Medical University, Ajman, UAE

Date of Web Publication21-May-2019

Correspondence Address:
Dr. Hossam Abdelatty Eid Abdelmagyd
Department of Oral Medicine and Periodontology, Faculty of Dentistry, Suez Canal University, Ismailia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_86_18

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  Abstract 


The study aimed at comparing the scalpel, laser, and abrasion techniques used in the treatment of gingival hyperpigmentation. Scalpel, laser, and abrasion techniques were used for gingival depigmentation in three adults with gingival hyperpigmentation. using scalpel technique in the removal of the hyperpigmented gingival epithelium, along with a layer of the underlying connective tissue, under adequate local anesthesia has an advantage when compared with other techniques used of being effective and requires minimum time and effort besides the least rate of recurrence. Gingival depigmentation using scalpel technique is superior when compared to abrasion and laser techniques.

Keywords: Abrasion technique, gingival hyperpigmentation, laser technique, scalpel technique


How to cite this article:
Abdelmagyd HA, Al-Ahmari MM, Shetty SR. Treatment of gingival hyperpigmentation using different techniques. J Datta Meghe Inst Med Sci Univ 2019;14:50-5

How to cite this URL:
Abdelmagyd HA, Al-Ahmari MM, Shetty SR. Treatment of gingival hyperpigmentation using different techniques. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Oct 18];14:50-5. Available from: http://www.journaldmims.com/text.asp?2019/14/1/50/258663




  Introduction Top


Oral melanin pigmentation is considered to be multifactorial, physiological/pathological. The main function of this pigment is photoprotection, from the ultraviolet (UV) rays. It may appear in the gingiva as early as 3 h after birth.[1] Melanin, a brown pigment, is the most common natural pigment contributing to endogenous pigmentation of the gingiva. It is a nonhemoglobin-derived pigment formed by cells called melanocytes which are dendritic cells of neuroectodermal origin in the basal and spinous layers.[2] The number of melanocytes is constant in fair and dark skin, but the activity of melanocyte is variable; the attached gingivae are the most frequently pigmented intraoral tissues (27.5%). Melanin pigmentation is mostly localized at the anterior labial gingiva.[3] The intensity and distribution of oral pigmentation are variable, between races, between different individuals of the same race, and within different areas of the same mouth. The degree of pigmentation depends on activity of melanocytes, genetic constitution, hormones, and UV radiation.[4] Classification of gingival pigmentation according to Dummett, 1971[5]– (a) Physiologic (racial): Melanin nonhemoglobin-derived brown pigment (most common) and (b) Pathologic: may be due to drug induced such as chloroquine, quinine, minocycline, and contraceptive, smoking-associated melanosis, heavy metals, e.g., lead, bismuth, mercury, silver, arsenic, and gold, and endocrine diseases such as Addison's disease. Smokers' melanosis has been reported in 22% of smokers and is dose dependent due to nicotine and benzopyrenes, which penetrate into the oral mucosa and activate melanocyte.[5]

In this study, the cases were selected based on Dummett–Gupta oral pigmentation index (DOPI) (Dummett, 1971):[5]

  1. No clinical pigmentation (pink gingiva)
  2. Mild clinical pigmentation (mild light brown color)
  3. Moderate clinical pigmentation (medium brown or mixed pink and brown)
  4. Heavy clinical pigmentation (deep brown or bluish black).


The smile line classification (Liebart and Deruelle, 2004):[6],[7]

  • Class 1: Very high smile line – >2 mm of the marginal gingiva visible
  • Class 2: High smile line – between 0 and 2 mm of the marginal gingiva visible
  • Class 3: Average smile line – only gingival embrasures visible
  • Class 4: Low smile line – gingival embrasures and cementoenamel junction not visible.


The present case series describes three surgical gingival depigmentation techniques – scalpel, abrasion, and diode lasers. Each patient was given a detailed explanation of the treatment plan and the expected rate of recurrence before they could sign the consent form.

Patient selection criteria

Inclusion criteria

Adult individuals aged from 25 to 35 years, systemic disease free, under no medication for any reason, nonpregnant females, and no history for any gingival depigmentation treatment were included.

Exclusion criteria

Individuals under 25 or above 35 years of age, history of systemic disease, history of gingival depigmentation treatment, under any medications, and pregnant females were excluded.


  Case Reports Top


Case report 1

A 25-year-old male without any history of systemic disease reported with complaint of complained of black gums. Clinical examination was carried out using DOPI [4] scoring system wherein a score of 1 means – No clinical pigmentation (pink gingiva), 2 – Mild clinical pigmentation (mild light brown color), 3 – Moderate clinical pigmentation (medium brown or mixed pink and brown), and 4 – Heavy clinical pigmentation (deep brown or bluish black). Examination revealed deeply pigmented gingiva from the right first canine to left first canine with score 4 [Figure 1]; considering the patient's concern, a scalpel surgical depigmentation procedure was planned. The entire procedure was explained to the patient and written consent was obtained, routine oral hygiene procedures were carried out, and oral hygiene instructions were given. Local anesthetic infiltration of 2% lignocaine containing adrenaline at a concentration of 1:80,000 was injected in the maxillary anterior region from the right first premolar to the left first premolar. This was followed by two incisions extending from the gingival margin to the vestibular area, a little beyond the limits of the pigmented band. These vertical incisions demarcate the surgical area. Bard Parker blade number 15 was held parallel to the gingival surface, scrapping of the pigmented epithelium up to the level of the mucogingival junction was carried out, and a portion of the computed tomography is gently dissected out from one end of the vertical incision. Care is taken not to tear the tissue or leave any pigmented posts behind or expose the bone. After complete removal of the entire epithelium, abrasion with diamond bur was done to get the physiological contour of the gingiva. Bur was used with minimal pressure with feather light brushing strokes. A periodontal dressing (Coe-Pak) was placed on the surgical wound area for patient comfort and to protect it for at least 1 week. The patient was kept on analgesics for 5 days and was advised to use 0.12% chlorhexidine gluconate mouthwash for 2 weeks postoperatively. During the postoperative period, the wound healing was uneventful without any discomfort. Six months postoperative examination showed well-epithelialized gingiva, which was pink and pleasant for the patient [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Figure 1: Preoperative picture showing melanin hyperpigmentation

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Figure 2: Intraoperative picture showing removal of pigmented gingival tissues using scalpel

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Figure 3: Using tweezers to remove pigmented gingival tissues

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Figure 4: Postoperative immediately following depigmentation

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Figure 5: One-month follow-up

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Figure 6: Three-month follow-up

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Figure 7: Six-month follow-up

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Case report 2

A 29-year-old female patient without any history of major systemic disease reported with complains of psychological depression due to bad aesthetics caused by black-colored pigmentation of upper and lower gingiva [Figure 8]. Clinical examination using DOPI[4] scoring revealed that the case score is 4. Generalized heavy black hyper-pigmentation of the gingiva in both arches was observed indicative of a score of 4. Abrasion technique using large-sized round diamond bur was planned for this case. After local anesthesia injection, a high-speed handpiece and copious water irrigation with round diamond bur (2 or 2.5 mm of diameter), feather, gentle light brushing strokes were used. Light brushing strokes and the bur were kept in motion all the time to avoid excessive heat generation and destruction of the tissues. The surgical area was covered with a periodontal dressing; postsurgical antibiotics (amoxicillin 500 mg, three times daily for 5 days) and analgesics (ibuprofen with paracetamol, three times daily for 3 days) were prescribed. The patient was advised to use chlorhexidine mouthwash 12 hourly for 1 week, and oral hygiene instructions were given. After removal of the pack (1 week), hyperpigmentation was absent in the newly formed epithelial tissues, with the gingiva appearing pale pink after a period of 1 month up to 9 months [Figure 9], [Figure 10], [Figure 11], [Figure 12].
Figure 8: Preoperative picture showing heavy melanin gingival hyperpigmentation

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Figure 9: Intraoperative picture showing depigmentation using diamond bur

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Figure 10: Postoperative immediately following abrasion

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Figure 11: Postoperative after 1 month

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Figure 12: Postoperative after 6 months

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Case report 3

A 27-year-old male heavy smoker patient complained of hyperpigmented gums seeking for optimal dental aesthetics appearance by treating his black gums. On clinical examination, his DOPI score was 3, and the patient had a high smile line [Figure 13]. After obtaining consent from the patient, the authors put the treatment plan using abrasion technique started by upper arch; surprisingly, after 1 month, repigmentation of the upper gingival tissues has been noticed. The dental work team decided to perform de-pigmentation for both arches gingivae using laser depigmentation procedure.
Figure 13: Preoperative picture showing gingival hyperpigmentation

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Laser technique

Before starting the procedure, both patient and the staffs were protected from laser by wearing manufacturer's spectacles. Adequate anesthesia was given; then, diode laser in contact mode was used; the ablation was operated using a handpiece with fiber optic filament, 320 μm in diameter set at 0.8 W. The procedure was performed in a contact mode in cervicoapical direction on all hyperpigmented areas. The use of water enhanced the visualization of the operative field and minimized heat generation by cooling the irradiated area and absorbing excessive laser energy during the procedure. Neither pain nor bleeding complications were observed during and after the procedure; the ablated wound healed completely in 1 week. Three months after the ablation, the gingiva was generalized pink and healthy in appearance with satisfactory esthetics by both patient and staff [Figure 14], [Figure 15], [Figure 16], [Figure 17].
Figure 14: After 1 month repigmentation of the upper gingiva

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Figure 15: Laser depigmentation for recurrence of upper gingiva

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Figure 16: Laser depigmentation for first time for lower gingiva

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Figure 17: Postoperative after 6 months

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  Discussion Top


Gingival depigmentation is a periodontal plastic surgical procedure in which the gingival hyperpigmentation is eliminated or reduced by different technique. Elimination of these melanotic areas can be done by several treatment modalities that have been suggested ranging from a simple scalpel method to sophisticated lasers.[7] Methods of depigmentation are scalpel technique, gingival abrasion technique gingivectomy, electrosurgery, cryosurgery, and chemical agents. Other methods aimed at masking the pigmented gingival from less pigmented gingival areas as free gingival graft and acellular dermal matrix allograft. The selection of technique should be based on clinical experience and individual preferences.[8] In the scalpel technique, gingival epithelium is removed along with a layer of the underlying connective tissue. The denuded tissue heals by secondary intention. This technique has an advantage of being effective and requires minimum time and effort; however, its disadvantage is mainly due to bleeding, postoperative pain, and discomfort.[9] The depigmentation procedure by scalpel technique is simple, easy to perform, noninvasive, and above all, cost-effective compared to other techniques. However, erbium: yttrium-aluminum-garnet (YAG) laser is more useful and safe in thin gingival biotype, and healing of wound is relatively fast and comparable to scalpel wound.[6],[10] According to the migration theory, active melanocytes from the adjacent pigmented tissues migrate to treated areas, causing repigmentation. Repigmentation was reported with nearly all methods. Bur abrasion has the highest rate of repigmentation by 8.89, followed by laser 1.16%, then electrosurgery 0.74, then cryosurgery 0.32, and then diode laser 0.19%, while repigmentation rate following scalpel technique may occur after 7 years.[11] According to Almas and Sadiq, the scalpel wound heals faster than that in other techniques. However, scalpel surgery causes unpleasant bleeding during and after the operation. It is also necessary to cover the exposed lamina propria with periodontal dressing for 7–10 days.[11],[12],[13],[14],[15] Our study results proved that the highest repigmentation recurrence rate and duration were recorded with using abrasion technique when compared to scalpel and laser techniques. Procedural discomfort are generally attributed to placement of periodontal pack, duration of procedure, recurrence of pigmentation. The recurrence of pigmentation is usually determined by genetic tendency or factors such as heavy smoking. Besides, the scalpel technique procedure is more convenient for both periodontists and patients, regarding duration and effort, and it is also more economical to the patient when compared to abrasion and laser techniques. Better results were obtained using laser technique when compared to other techniques used in this study when recurrence rate was considered. This may be explained on the basis of the fact that neodymium: YAG laser produces effects at tissue depths of 4–6 mm. Lasers also demonstrate particular affinity for melanin or other dark pigments. When comparing laser technique with the other techniques, it is minimally invasive, convenient, fast, and safe upon following manufacturer's instructions, and no severe pain intra- and post-operatively has been recorded. The proved antimicrobial effects of laser may be the reason behind the reduced infection, swelling, and less bleeding; these findings in our study are in accordance with the studies by Giannelli et al., 2014[15] and Kishore et al., 2014.[16]


  Conclusion Top


Gingival depigmentation using scalpel method has an advantage of being effective and requires minimum time and effort with the lowest rate of repigmentation compared to laser and abrasion methods.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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

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2.
Eid HA, Syed S, Soliman AN. The role of gingival melanin pigmentation in inflammation of gingiva, based on genetic analysis. J Int Oral Health 2013;5:1-7.  Back to cited text no. 2
    
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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. 3
    
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Ozbayrak S, Dumlu A, Ercalik-Yalcinkaya S. Treatment of melanin-pigmented gingiva and oral mucosa by CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:14-5.  Back to cited text no. 4
    
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Dummett CO, Barens G. Oromucosal pigmentation: An updated literary review. J Periodontol 1971;42:726-36.  Back to cited text no. 5
    
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Madan E, Madan R, Chaubey KK, Agarwal MC. Gingival depigmentation-an array of treatment modalities. Int J Rec Sci Res 2015;6:7627-31.  Back to cited text no. 6
    
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Liebart ME, Deruelle CF, Santini A, Dillier FL, Corti VM. Smile line and periodontium visibility. Periodontology 2004;1:17-25.  Back to cited text no. 7
    
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Ishikawa I, Aoki A, Takasaki AA. Potential applications of Erbium: YAG laser in periodontics. J Periodontal Res 2004;39:275-85.  Back to cited text no. 8
    
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Kathariya R, Pradeep AR. Split mouth de-epithelization techniques for gingival depigmentation: A case series and review of literature. J Indian Soc Periodontol 2011;15:161-8.  Back to cited text no. 9
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Verma SK, Maheshwari S, Singh RK, Chaudhari PK. Laser in dentistry: An innovative tool in modern dental practice. Natl J Maxillofac Surg 2012;3:124-32.  Back to cited text no. 10
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Prasad SS, Neeraj A, Reddy NR. Gingival depigmentation: A case report. Peoples J Sci Res 2010;3:27-9.  Back to cited text no. 11
    
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Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.  Back to cited text no. 12
    
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Sushma L, Yogesh D, Marawarc PP. Management of gingival hyperpigmentation using surgical blade and diode laser therapy: A comparative study. J Oral Laser Appl 2009;9:41-7.  Back to cited text no. 13
    
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Almas K, Sadig W. Surgical treatment of melanin-pigmented gingiva; an esthetic approach. Indian J Dent Res 2002;13:70-3.  Back to cited text no. 14
    
15.
Giannelli M, Formigli L, Bani D. Comparative evaluation of photoablative efficacy of erbium: Yttrium-aluminium-garnet and diode laser for the treatment of gingival hyperpigmentation. A randomized split-mouth clinical trial. J Periodontol 2014;85:554-61.  Back to cited text no. 15
    
16.
Kishore A, Kathariya R, Deshmukh V, Vaze S, Khalia N, Dandgaval R, et al. Effectiveness of Er: YAG and CO2 lasers in the management of gingival melanin hyperpigmentation. Oral Health Dent Manag 2014;13:486-91.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]



 

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