|Year : 2016 | Volume
| Issue : 1 | Page : 13-16
A comparative evaluation of two different techniques for esthetic management of gingival melanin hyperpigmentation: A clinical study
Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia
|Date of Web Publication||12-Apr-2016|
Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Introduction: The color of gingiva influences the smile of person and affects esthetics, the present study was conducted to evaluate the effect of gingival depigmentation by scalpel and electrosurgery. Materials and Methods: A total number of 18 patients, 16 males and two females, aged between 18 and 30 years, reported to the clinic, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, complaining of "grayish-blackish gums" which affected the esthetics of their smile. The treatment done in this study was scalpel surgical technique and electrocautery as they could be easily done and were less time consuming. Healing and recurrence of pigmentation were postoperatively evaluated. Intraoral pictures were taken at every follow-up visit to compare the progress and also to access the occurrence of any repigmentation. One-way ANOVA and unpaired t-test were used for statistical analysis. Results: There was statistically significant reduction seen for both the study techniques after 6 months postoperatively as compared to baseline with no complications leading to pain, infection, bleeding, or scarring postoperatively. During the 6 th month follow-up, there were no signs of repigmentation in both the treatment modalities. Cases were followed up for any reoccurrences of pigmentation longitudinally. Conclusion: Satisfactory results were obtained with both the surgical and electrocautery procedures for gingival depigmentation. Hence, the surgical technique still serves as the simplest and effective depigmentation technique. During the follow-up period, no recurrence of gingival hyperpigmentation was found with both the techniques employed in this study.
Keywords: Depigmentation, electrocautery, gingival melanin hyperpigmentation, scalpel
|How to cite this article:|
Gufran K. A comparative evaluation of two different techniques for esthetic management of gingival melanin hyperpigmentation: A clinical study. J Dent Res Rev 2016;3:13-6
|How to cite this URL:|
Gufran K. A comparative evaluation of two different techniques for esthetic management of gingival melanin hyperpigmentation: A clinical study. J Dent Res Rev [serial online] 2016 [cited 2023 Mar 27];3:13-6. Available from: https://www.jdrr.org/text.asp?2016/3/1/13/180109
| Introduction|| |
A smile is the nonverbal communication of person in his social life. Two main factors that can affect a confident smile are teeth and the gums. Various factors add to the beautiful smile such as teeth color, gingival color, and position of the teeth in the oral cavity. The color of the gingival surface is decided by the number and size of blood vessels, the degree of keratinization, the colored pigments within the epithelium, and thickness of the epithelium. 
Melanin is produced by melanoblasts in gingival epithelium with adds the brown color to the gingiva. Gingiva happens to be the highly pigmented part of the oral mucosa.  The variation in the degree of gingival hyperpigmentation among different populations is considered a racial trait and is not related to gender or age of the individual. , Hyperpigmentation is related to the melanoblastic activity of the epithelial cells in gingiva, its degree differs from person to person. 
Usually, the occurrence of gingival pigmentation is persistent and symmetrical without causing any alteration of the gingival structure. Gingival melanin pigmentation is mostly observed in African and East Asian population as its predilection is more in dark skinned ethnic populations. , People suffering from certain medical conditions such as Addison's disease also show increased preponderance of gingival pigmentation. 
Literature search reports numerous techniques to treat depigmentation and to enhance esthetics. ,,, Surgical blade de-epithelization is an effective technique which is simpler and more economical than most of the available techniques.  Electrosurgery is another commonly used technique for effective depigmentation but it requires more expertise and prolonged application of electrical current which can cause tissue destruction.  This study was conducted to evaluate the effect of gingival depigmentation by scalpel and electrosurgery on patient's satisfaction, healing, and recurrence of pigmentation.
| Materials and Methods|| |
The clinical trial was conducted at College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia. Ethical clearance for the study was obtained from the Institutional Ethical Committee.
Eighteen patients (16 males and two females) aged 18-30 years who reported to the clinic, with the chief complaint of "grayish-blackish gums" which affected the esthetics of their smile were recruited for the study. A comprehensive medical history was taken. The patients were enquired about systemic diseases and medications related to the gingival melanin pigmentation and patients with a positive history for such conditions were excluded from the study. Patients with acute pulpal or periodontal pathologies were excluded from the study. Written informed consent was obtained from all participants after explaining to them the purpose and procedures involved in the study.
Oral prophylaxis was carried out as a part of the first phase of the periodontal treatment, and oral hygiene instructions were given to the patients. After the complete remission of gingival inflammation, the depigmentation procedure was performed.
The subjects were randomly divided into two study groups:
- Group I: Surgical blade technique
- Group II: Electrocautery technique.
Clinical gingival melanin pigmentation assessment was made pre- and post-operatively according to Dummett-Gupta Oral Pigmentation Index scoring criteria by Dummett and Gupta: 
- 0 - No pigmentation (pink gingiva)
- 1 - Mild pigmentation (mild light brown color)
- 2 - Moderate pigmentation (medium brown or mixed pink and brown color)
- 3 - Heavy pigmentation (deep brown or bluish black color).
Observation for gingival pigmentation score was done in natural light. Two investigators made the observations, and the degree of hyperpigmentation was scored according to the agreement between the two investigators. Intraexaminer calibration was done before the study and was found to be satisfactory (Cohen's kappa = 0.8).
Surgical blade technique (Group I)
Surgical gingival de-epithelization procedure was performed using the scalpel technique. Local anesthetic was administered to the surgical site. Blade no. 15 with Bard-Parker handle was used to scrape the epithelium along with the underlying pigmented layer from the first premolar to first premolar for both the arches. The raw surface was irrigated with saline solution. A pressure pack was placed using sterile gauze to control the bleeding. Care was taken to avoid bone exposure by removal. After completion of the procedure, a periodontal pack was placed at the surgical site. Postoperative instructions were given in the language of the patients' choice [Figure 1].
|Figure 1: Gingival depigmentation by the surgical blade. (a) Preoperative; (b) after de-epithelialization; (c) postoperative - 6 months|
Click here to view
Electrosurgical gingival depigmentation (Group II)
Electrocautery unit was used to de-epithelize the hyperpigmented areas. Ablation of the effected tissues was carried out under standard protective measures using loop electrode of the electrocautery unit. The procedure was done with great caution as prolonged contact with one area can lead to tissue damage due to excessive heat. Therefore, the tip was kept in constant motion, and light brushing strokes were used. Saline-soaked sterile gauze was used to remove the excised tissue fragments. This technique was followed till the desired amount of pigmented tissue was ablated. After completion of the procedure, a periodontal pack was placed at the surgical site. Postoperative instructions were given in the language of the patients' choice [Figure 2].
|Figure 2: Gingival depigmentation by electrocautery. (a) Preoperative; (b) use of loop electrode; (c) after de-epithelialization; (d) postoperative - 6 months|
Click here to view
Pain management was achieved using analgesics and the periodontal dressings were removed after 1 week. Patients were recalled every week for 3 weeks postoperatively to observe healing and to assess the level of patient comfort following the procedure.
Re-evaluation of the clinical parameters
The degree of gingival depigmentation and recurrence and intensity of gingival melanin pigmentation were recorded at 1 month and 6 months postoperatively.
Mean and standard deviations of the score were computed. Unpaired t-test was used to assess the difference between the groups in relation to the degree of depigmentation and the extent of repigmentation. One-way ANOVA was used for the intragroup comparison followed by Tukey's post hoc test for pairwise comparisons. A P < 0.05 was considered statistically significant.
| Results|| |
The results achieved for all the patients were satisfactory and pleasant. No postoperative complications such as pain, infection, bleeding, or scarring was observed during the follow-up visits in both the study groups. The patients from both study groups were recalled for a follow-up up at 1 month and 6 months. There were no signs of repigmentation and the patients are being monitored longitudinally (once a month) for any reoccurrences of pigmentation.
[Table 1] shows the intragroup comparison of the mean Dummett-Gupta Oral Pigmentation Index score at baseline, 1 month, and 6 months. It can be observed that there was statistically significant reduction seen for both the study techniques 6 months postoperatively as compared to baseline.
|Table 1: Intragroup comparison of the mean Dummett-Gupta Oral Pigmentation Index score at baseline, 1 and 6 months|
Click here to view
[Table 2] shows the comparison of the mean Dummett-Gupta Oral Pigmentation Index score at baseline, 1 month, and 6 months. It can be observed that there was no statistically significant difference seen between the two study techniques 6 months postoperatively.
|Table 2: Comparison of the mean Dummett-Gupta Oral Pigmentation Index score|
Click here to view
| Discussion|| |
Gingival hyperpigmentation is the cause for esthetic concern for many patients. Literature search reports numerous techniques to treat depigmentation and to enhance esthetics. ,,, Surgical blade de-epithelization is an effective technique which is simpler and more economical than most of the available techniques.  Electrosurgery is another commonly used technique for effective depigmentation, but it requires more expertise and prolonged application of electrical current which thereby can cause tissue destruction and is this detrimental.  This study was thus undertaken to compare these two techniques for esthetic management of gingival melanin hyperpigmentation.
The anterior sextant being the most esthetically distinct region in the oral cavity was chosen for the study, and gingival depigmentation is essentially undertaken to satisfy the esthetic needs of the patients. Literature shows that anteriorly attached gingiva is more pigmented than the posterior as it is more exposed to light.  It has been observed that after the initial reduction in pigmentation mean score after the procedure, the rate and intensity of repigmentation were more in the anterior sextant than the posterior sextant.  The effect of sunlight on the anterior segment has been quoted as the reason for this difference. ,,
No statistically significant difference in the depigmentation score was observed between Group I and Group II at 1 month and 6 months. The effectiveness of surgical blade technique and electrocautery has been demonstrated in several previous studies. ,, In a case series, split mouth de-epithelization procedure using a scalpel, bur abrasion and electrosurgery were successfully used to treat gingival hyperpigmentation.  It was reported that electrosurgery required a lot of precision but increased the efficacy of work, giving a cleaner and neater work field.  Scalpel de-epithelization was reported to be easier and gave excellent results and patient satisfaction. 
In another case series, it was found that scraping, electrosurgery, and diode laser were simple, effective, and yielded good results as well as patient satisfaction. 
The repigmentation was assessed at the end of 1 month and 6 months. The reappearance of melanin pigment following a period of clinical depigmentation is referred to as repigmentation. The proliferation of melanocytes from the normal skin and their migration into the depigmented areas has been suggested as the mechanism for spontaneous repigmentation.  Perlmutter and Tal have reported that no permanent results are seen with gingival surgical procedures performed solely for cosmetic reasons.  Repigmentation was seen in 50% of the cases between 24 and 55 days in a study conducted by Ginwalla et al.  A case series by Deepak et al. had shown that bur abrasion, scraping, partial thickness flap, cryotherapy, and electrosurgery for depigmentation were simple, effective, and yielded good results, along with good patient satisfaction.  This study is limited by the number of subjects. Furthermore, the patient's complexion was not taken into account concerning the degree of pigmentation and the rate of repigmentation. Gingival melanin pigmentation is mostly observed in African and East Asian population as its predilection is more in dark skinned ethnic populations. , However, it can be inferred from the study that both scalpel technique, as well as electrocautery, can be successfully used in the treatment of gingival pigmentation.
| Conclusion|| |
To conclude, both the surgical and electrocautery procedures for gingival depigmentation in this study were satisfactory and yielded acceptable results. However, the surgical technique still serves as the simplest depigmentation technique.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dummett CO. Oral pigmentation. First symposium of oral pigmentation. J Periodontol 1960;31:356-60.
Ciçek Y, Ertas U. The normal and pathological pigmentation of oral mucous membrane: A review. J Contemp Dent Pract 2003;4:76-86.
Dummett CO, Barens G. Oromucosal pigmentation: An updated literary review. J Periodontol 1971;42:726-36.
Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.
Fry L, Almeyda JR. The incidence of buccal pigmentation in caucasoids and negroids in Britain. Br J Dermatol 1968;80:244-7.
Tamizi M, Taheri M. Treatment of severe physiologic gingival pigmentation with free gingival autograft. Quintessence Int 1996;27:555-8.
Almas K, Sadig W. Surgical treatment of melanin-pigmented gingiva; an esthetic approach. Indian J Dent Res 2002;13:70-3.
Dummett CO, Gupta OP. Estimating the epidemiology of oral pigmentation. J Natl Med Assoc 1964;56:419-20.
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.
Raut RB, Baretto MA, Mehta FS, Sanjana MK, Shourie KL. Gingival pigmentation: Its incidence amongst the Indian adults. J Am Dent Assoc 1954;26:9-10.
Kaur H, Jain S, Sharma RL. Duration of reappearance of gingival melanin pigmentation after surgical removal - A clinical study. J Indian Soc Periodontol 2010;14:101-5.
Thangavelu A, Elavarasu S, Jayapalan P. Pink esthetics in periodontics - Gingival depigmentation: A case series. J Pharm Bioallied Sci 2012;4 Suppl 2:S186-90.
Sucheta A, Prasad R, Laksmi P, Apoorva SM, Bhata D, Bhopale D. Depigmentation: To beautify a smile. Ann Dent Res 2014;3:52-94.
Ginwalla TM, Gomes BC, Varma BR. Surgical removal of gingival pigmentation. (A preliminary study). J Indian Dent Assoc 1966;38:147-50.
Deepak P, Sunil S, Mishra R, Sheshadri. Treatment of gingival pigmentation: A case series. Indian J Dent Res 2005;16:171-6.
[Figure 1], [Figure 2]
[Table 1], [Table 2]
|This article has been cited by|
||Transepithelial Gingival Depigmentation Using a New Protocol with Q-Switched Nd:YAG: An In Vivo Observational Study
| ||Niccolò Giuseppe Armogida, Carlo Rengo, Mariangela Cernera, Flavia Iaculli, Gianrico Spagnuolo |
| ||Dentistry Journal. 2022; 11(1): 2 |
|[Pubmed] | [DOI]|
||Gingival depigmentation with diode and Er,Cr:YSGG laser: evaluating re-pigmentation rate and patient perceptions
| ||Walid Altayeb,Omar Hamadah,Bahaa Aldin Alhaffar,Ahmed Abdullah,Georgios Romanos |
| ||Clinical Oral Investigations. 2021; |
|[Pubmed] | [DOI]|
||A Pink Smile: Depigmentation Using Diode Laser and Surgical Scalpel
| ||Biju Thomas,Shiny Inasu |
| ||International Journal of Experimental Dental Science. 2021; 10(1): 41 |
|[Pubmed] | [DOI]|
||Laser-Assisted Depigmentation—An Introspection of the Science, Techniques, and Perceptions
| ||Alex Mathews Muruppel,B.S. Jagadish Pai,Subraya Bhat,Steven Parker,Edward Lynch |
| ||Dentistry Journal. 2020; 8(3): 88 |
|[Pubmed] | [DOI]|