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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 81-84

Management of gingival pigmentation using laser depigmentation technique


Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India

Date of Submission26-May-2021
Date of Decision16-Jun-2021
Date of Acceptance20-Jul-2021
Date of Web Publication25-Aug-2021

Correspondence Address:
Dhirendra Kumar Singh
Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcdoh.jpcdoh_22_21

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  Abstract 


Gingival hyperpigmentation can be defined as a darker gingival color beyond what is normally expected. Several by-products of the physiological process such as melanin, oxyhemoglobin, carotene, reduced hemoglobin, and iron and/or pathological diseases and conditions are most commonly the contributors of pigmentation. Either it can be due to melanin pigmentation results produced by melanoblasts or environmental risk factors such as tobacco smoking. Pigmentation of the gingiva not just has an impact on esthetics and may range from physiologic reasons (e.g. racial pigmentation) to manifestations of systemic illnesses (e.g. Addison's disease) to malignant neoplasms (e.g. melanoma and Kaposi's sarcoma). Therefore, an insight understanding is necessary of the cause for mucosal pigmentation before planning the treatment. Gingival depigmentation can be achieved using a wide range of procedures, i.e. depigmentation such as bur abrasion, scraping, cryotherapy, electrosurgery, and laser. In the present case report, a laser depigmentation technique was used which is simple and yields good results along with good patient satisfaction.

Keywords: Gingival depigmentation, gingival pigmentation, laser, periodontal plastic surgery


How to cite this article:
Singh DK, Mandal A. Management of gingival pigmentation using laser depigmentation technique. J Prim Care Dent Oral Health 2021;2:81-4

How to cite this URL:
Singh DK, Mandal A. Management of gingival pigmentation using laser depigmentation technique. J Prim Care Dent Oral Health [serial online] 2021 [cited 2021 Dec 3];2:81-4. Available from: http://www.jpcdoh.org/text.asp?2021/2/3/81/324540




  Introduction Top


Physiological pigmentation of the oral mucosa is clinically manifested as multifocal or diffuse melanin pigmentation with the variable amount in different ethnic groups.[1a, 1b] Among various factors leading to gingival pigmentation, melanin, a brown pigment, seems to be the most common endogenous source.[2] Clinical gingival pigmentation does not indicate a medical problem, “black gums” may cause complaints regarding esthetic problems, particularly in patients with a high smile line. The etiology could be physiological or pathological and it may occur in all human races and countries. Gingival hyperpigmentation can be defined as a darker gingival color beyond what is normally expected. Several by-products of the physiological process such as melanin, oxyhemoglobin, carotene, reduced hemoglobin, and iron and/or pathological diseases and conditions are most commonly the contributors of pigmentation. It has been also found that few gingival pigmented lesions get converted into gingival malignancy. Furthermore, the treatment of gingival pigmentation does not only give esthetic results but also acts as a primary dental care procedure that prevents future gingival malignancy.

Gingival depigmentation can be defined as a periodontal plastic surgery technique whereby the hyperpigmented gingival pigmentation is removed or reduced by various procedures. Gingival depigmentation can be achieved using a wide range of procedures, i.e. depigmentation such as bur abrasion, scraping, cryotherapy, electrosurgery, and laser. In the present case report, a scraping technique was used which is simple and yields good results and gold standard along with good patient satisfaction.


  Case Report Top


A 25-year-old male patient reported to the Department of Periodontology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, with a chief complaint of blackish discoloration in his upper and lower front gum region for 5 years [Figure 1] which he felt as esthetically unappealing while smiling. On further history recording, no association of symptoms like ulceration, paranesthesia was found with the discoloration. However, the patient was found to have the habit of cigarette smoking for the last 5 years. He also gave a history of dental treatment of scaling and oral prophylaxis. He was systemically healthy and with no other such reported adverse systemic health conditions, and was willing to undergo surgical intervention. Clinical examination revealed that he had deeply pigmented gingiva from right molars extending to left molars on both maxillary and mandibular arches which can be categorized as diffused gingival melanin pigmentation in accordance with maxillary arch: Hedin's classification – Grade IV and mandibular arch: Hedin's classification – Grade III.
Figure 1: Diffused gingival melanin pigmentation IRT maxillary and mandibular arches, i.e. maxillary arch: Hedin's classification – Grade IV, mandibular arch: Hedin's classification – Grade III

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Various conventional surgical methods such as scalpel surgical technique, cryosurgery, and electrosurgery are recommended for gingival depigmentation along with recently newer procedures such as neodymium-doped yttrium–aluminum–garnet lasers, diode lasers, erbium-doped yttrium–aluminum–garnet lasers, and carbon dioxide. After proper treatment planning and the patient's desire, the laser method of depigmentation was planned. The local anesthetic solution of 2% of lignocaine with adrenaline was administered in the maxillary anterior region, as the patient was apprehensive to the procedure, otherwise, a local spray of surface anesthesia is more than enough for any kind of laser-assisted treatment procedure, a type IV laser diode, ma × 1 mW, 635 nm laser with 300 μm diameter of the tip was used to remove the pigmented layer [Figure 2]a and [Figure 2]b. The entire melanin-pigmented epithelium along with a thin layer of connective tissue was removed by the laser scraping technique. A continuous cleaning procedure was applied at the surgical site with moist sterile gauze to clean the surgical area for better visibility during the procedure. After the removal of all remnants of the pigment layer, normal saline solution was used to irrigate the exposed surface. The surgical area was covered with a periodontal dressing. Post-surgical instructions were given to the patient along with the prescription of anti-inflammatory & analgesics (ibuprofen with paracetamol twice daily for 3 days). The patient was also advised to use 0.2% chlorhexidine gluconate mouthwash 2–3 times a day for 2 weeks.
Figure 2: (a) Laser surgery was planned to perform the depigmentation to remove the pigmented layer. (b) Post depigmentation procedure

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The patient was again recalled at the 1st week and then after 1 month and 6 months for revaluation. Postoperatively, the patient had no complications in regard to pain or sensitivity. However, post 3 months, certain localized areas of repigmentation were seen with no further repigmentation by the end of 6 months [Figure 3].
Figure 3: Gingival healing status after the 6 months of Laser depigmentation surgery

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  Discussion Top


The prevalence of oral pigmentation is the same in all races of individuals; no significant difference has been found between males and females. The fate of gingival color primarily depends on four factors, i.e. vascular supply, the thickness of the gingiva, degree of keratinization of epithelium, and the presence of pigment-containing cells (melanocytes). The distribution and intensity of pigmentation are variable in all aspects. Several by-products of the physiological process such as melanin, oxyhemoglobin, carotene, reduced hemoglobin, and iron and/or pathological diseases and conditions are most commonly the contributors of pigmentation. Gingival pigmentation can either be due to melanin pigmentation which is produced by melanoblasts or environmental risk factors such as tobacco smoking. Pigmentation of the gingiva not just has an impact on esthetics and may range from physiologic reasons (e.g. racial pigmentation) to manifestations of systemic illnesses (e.g. Addison's disease) to malignant neoplasms (e.g. melanoma and Kaposi's sarcoma). Therefore, an insight understanding is necessary of the cause for mucosal pigmentation before planning the treatment. Gingival depigmentation constitutes a wide range of procedures, i.e. depigmentation such as bur abrasion, scraping, cryotherapy, electrosurgery, and laser.[3] The factors that decide the selection of the gingival depigmentation technique include clinical experience, patient's affordability, and an individual preference of the clinician.[4] Physiologic pigmentation is probably genetically determined, but as Dummet (1960) suggested, the degree of pigmentation is partially related to mechanical, chemical, and physical stimulation.[1] Ranganath et al. in their case report found that gingival depigmentation using a scalpel technique, was easy to perform, cost-effective, and above all, it causes minimum discomfort to the patients with excellent results and patient satisfaction, which is as per the present case report.[5] Recently, a systematic review and meta-analysis were done to identify the most effective treatment modality for managing generalized physiological gingival pigmentation, where they have reviewed 25 articles. By this, they concluded that surgical stripping has been the most conventional and gold standard treatment of choice, although this review also showed that newer techniques are equally effective or even better. Especially, diode laser was found to be the most frequently used procedure and showed better esthetic outcomes, lesser pain, faster healing, and patients' compliance and satisfaction after treatment.[6] The reason behind the surgical scalpel technique considered to be the “gold standard” procedure for the treatment of gingival melanin pigmentation is the armamentarium and cost-effectiveness of the procedure.[7] Studies have shown that the diode laser technique provides better hemostasis and good visibility at the surgical site and better postoperative patient comfort. Hence, both the techniques can be used for depigmentation procedures depending on the intensity, severity and gingival biotype, and patient acceptance.[8] After going through multiple pieces of literature, it was stated that it took almost 6 weeks for healing and the surgical site was left with a subtle scar.[9] However, in the present case, there was no scar formation post healing time that was 2–3 weeks. The results obtained were admirable with 3-month and 6-month follow-up. Although in some studies, satisfactory results were seen with the cryosurgery and laser therapy modalities, with a disadvantage, as they required refined equipment which is costly and having affordability issues by both the clinician as and patient. This is why consideration of the equipment constraints is highly recommended that the scalpel surgical procedure still exists as a gold standard procedure and treatment of choice for gingival depigmentation in most circumstances.

Repigmentation is a regularly seen problem with depigmentation procedures, although in the initial days of depigmentation surgery, the result seems to be highly encouraging. Repigmentation has been described as spontaneous and attributed to the activity and migration of melanocytic cells from surrounding areas. The mechanism of repigmentation is not understood completely, but according to the “migration theory,” active melanocytes from adjacent pigmented tissues migrate to treated areas causing repigmentation.[10] Gingival repigmentation has been documented, following the surgical procedure, within 24-day to 8-year long period.[11],[12],[13] In the present case, certain localized areas of repigmentation were seen which did not progress and no other areas of repigmentation were reported at the end of 6 months of post depigmentation procedure which goes per the case series reported by Eser Elemek in 2018.[14]


  Conclusion Top


In the modern era of the growing age and smile-consciousness, there is a growing demand for esthetic dental treatment. Gingival pigmentation, though not a major complication, greatly affects facial appearance. The patient's medical history is important in determining its cause whether physiological or pathological, but the histopathological examination is conclusive. Accordingly, treatment of the pigmentation is determined either surgically or chemically. The gingival depigmentation using surgical approach described in this case report was found to be a simple, economical, and clinically effective treatment modality for the management of gingival melanin pigmentation leading to an esthetically pleasing outcome. More good-quality randomized controlled trials with different depigmentation methods are needed to draw strong conclusions.

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.
1a. Ciçek Y, Ertaş U. The normal and pathological pigmentation of oral mucous membrane: A review. J Contemp Dent Pract 2003;4:76-86. 1b. Dhirendra S. Gingival diseases: World and Indian Scenario a Background Check. Glob J Med Res 2015;15:23-7.  Back to cited text no. 1
    
2.
Dummett CO, Barens G. Oromucosal pigmentation: An updated literary review. J Periodontol 1971;42:726-36.  Back to cited text no. 2
    
3.
Moneim RA, El Deeb M, Rabea AA. Gingival pigmentation (cause, treatment, and histological preview). Future Dent J 2017;3:1-7.  Back to cited text no. 3
    
4.
Roshna T, Nandakumar K. Anterior esthetic gingival depigmentation and crown lengthening: Report of a case. J Contemp Dent Pract 2005;6:139-47.  Back to cited text no. 4
    
5.
Ranganath MJ, Ramakrishnan T, Vidya Sekhar MN, Ebenezer M, Anithadevi S. Black to pink: A case report of treating gingival hyperpigmentation. Int J Cur Res Rev 2017;9:14.  Back to cited text no. 5
    
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Gul M, Hameed MH, Nazeer MR, Ghafoor R, Khan FR. Most effective method for the management of physiologic gingival hyperpigmentation: A systematic review and meta-analysis. J Indian Soc Periodontol 2019;23:203-15.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Chandra GB, VinayKumar MB, Walavalkar NN, Vandana KL, Vardhan PK. Evaluation of surgical scalpel versus semiconductor diode laser techniques in the management of gingival melanin hyperpigmentation: A split-mouth randomized clinical comparative study. J Indian Soc Periodontol 2020;24:47-53.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Nagati RR, Ragul M, Al-Qahtani N, Ravi KS, Tikare S, Pasupuleti MK. Clinical effectiveness of gingival depigmentation using conventional surgical scrapping and diode laser technique: A quasi-experimental study. Glob J Health Sci 2017;9:296.  Back to cited text no. 8
    
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Dummett CO, Bolden TE. Post-Surgical clinical repigmentation of the gingiva. Oral Surg Oral Med Oral Pathol 1963;16:353-65.  Back to cited text no. 9
    
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Mokeem SA. Management of gingival hyperpigmentation by surgical abrasion: Report of three cases. Saudi Dent J 2006;18:162-6.  Back to cited text no. 10
    
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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. 11
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12.
Altayeb W, Hamadah O, Alhaffar BA, Abdullah A, Romanos G. Gingival depigmentation with diode and Er,Cr:YSGG laser: Evaluating re-pigmentation rate and patient perceptions. Clin Oral Investig 2021. doi: 10.1007/s00784-021-03843-6.  Back to cited text no. 12
    
13.
Somit J, Nina S, Mehul C, Amitha R. A comparative clinical study on surgical blade and diode laser in the treatment of gingival melanin pigmentation. J Evol Med Dent Sci 2021;10:689-93.  Back to cited text no. 13
    
14.
Elemek E. Gingival melanin depigmentation by 810 nm diode laser. Eur J Dent 2018;12:149-52.  Back to cited text no. 14
[PUBMED]  [Full text]  


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