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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 112-114

Oral repigmentation after depigmentation − A short review and case report


Department of Periodontics, Faculty of Dentistry, Melaka-Manipal Medical College, Melaka, Malaysia

Date of Web Publication1-Dec-2017

Correspondence Address:
Rajesh Hosadurga
Department of Periodontics, Faculty of Dentistry, Melaka-Manipal Medical College, Melaka 75150
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5847.219674

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  Abstract 


Melanin is a pigment that contributes to skin and causes the physiological pigmentation of gingiva. Excess melanin causes hyperpigmentation. It can affect the appearance and self-esteem of the patients. Gingival hyperpigmentation can be treated by several treatment modalities. Repigmentation occurs post-surgery regardless of the procedure used, but the intensity and degree vary. In spite of recurrence, depigmentation procedures can result in improved gingival appearance. In the present case, the patient complained of black gums. On examination, hyperpigmented gingiva with short clinical crown and aberrant frenal attachment with midline diastema were noted. It was treated by surgical depigmentation, gingivectomy to increase the crown length and frenectomy to correct aberrant frenal attachment. The patient did not agree for midline diastema closure. Gingival pigmentation index was used to grade gingival pigmentation. The gingival aesthetics improved at the end of 5 months.

Keywords: Diastema, gingiva, gingival diseases, hyperpigmentation, melanin


How to cite this article:
Hosadurga R, Nettemu SK, Nettem S, Singh VP. Oral repigmentation after depigmentation − A short review and case report. Pigment Int 2017;4:112-4

How to cite this URL:
Hosadurga R, Nettemu SK, Nettem S, Singh VP. Oral repigmentation after depigmentation − A short review and case report. Pigment Int [serial online] 2017 [cited 2018 Sep 19];4:112-4. Available from: http://www.pigmentinternational.com/text.asp?2017/4/2/112/219674




  Introduction Top


Melanin, a non-haemoglobin-derived brown pigment, causes the endogenous discoloration of gingiva. Several factors affect gingival pigmentation.[1] Melanin pigmentation is present in all races of the humanity.[2] The skin colour and intensity of gingival pigmentation have shown positive correlation in Indian population.[3] The diversity of range of pigmentation depends on geographical location and genetics.[4]

Gingival hyperpigmentation is the increased pigmentation beyond the normally expected pigmentation of the gingiva.[5] Gingival hyperpigmentation can cause aesthetic problem in individuals with gummy smile. They request treatment for the dark gums.[6] The depigmentation of these melanotic areas has been achieved through many surgical procedures.[7]

The present case describes an aesthetic treatment approach involving surgical depigmentation, correction of aberrant frenum and crown lengthening.


  Case report Top


A 22-year-old female patient reported with a complaint of ‘black gums and small teeth’ to the outpatient department. She was dark complexioned and non-smoker. Intra-oral examination showed diffuse hyperpigmentation of gingiva extending from central incisor to last molar in both the arches. Only 50–60% of the anatomic crown was visible with false pocket of 4–5 mm in upper and lower anterior with no clinical attachment loss (altered passive eruption Type IA) [Refer [Table 1]].[8] There was midline diastema with papillary penetrating aberrant frenum [Figure 1]. Score ’3’ gingival hyperpigmentation was noted in the anterior teeth as per gingival pigmentation index (GPI).[9] The patient did not have any systemic conditions that would contra-indicate surgery. After obtaining informed consent, management included non-surgical therapy, followed by gingivectomy for crown lengthening in the aesthetic zone (from premolar to premolar), maxillary labial frenectomy and sub-epithelial excision with No. 15 surgical blade for depigmentation under local anaesthesia [[Figure 1],[Figure 2],[Figure 3]].
Table 1: Classification of altered passive eruption and treatment options[8]]

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Figure 1: Preoperative photograph

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Figure 2: Depigmentation, crown lengthening and frenectomy

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Figure 3: Post-operative photograph after 2 months showing mild repigmentation (score 1 as per Gingival Pigmentation Index)

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Post-operatively, diclofenac sodium 50 mg for 2 days for analgesia and 0.12% chlorhexidine (for 2 weeks) antiseptic mouth rinse were prescribed. There were no adverse events during post-surgical healing. Two months post-surgery, small flecks of repigmentation and 5 months post-surgery, score ’2’ pigmentation as per GPI were seen [Figure 4], but the intensity had reduced. The gingival aesthetics improved and the patient found the post-operative results satisfactory. However, she was not available for further follow-up, because she shifted her residence.
Figure 4: Post-operative photograph after 5 months showing repigmentation (score 2 as per Gingival Pigmentation Index)

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  Discussion Top


Active melanocytes in the basal and suprabasal layer of gingival epithelium cause melanin pigmentation. Dummett suggested that the degree of pigmentation is dependent on many factors, including chemical, mechanical and physical stimulation.[10] However, Stokowski et al. reported a significant genetic association between skin pigmentation and genetics.[4] Physiological melanin hyperpigmentation causes significant aesthetic concern for the patients and make them seek treatment. Many techniques are available to treat gingival hyperpigmentation.[9] But sub-epithelial excision with scalpel is a simple, efficient and cost-effective technique for depigmentation. There is no need of sophisticated equipment and it can be routinely performed in the clinical scenario. Hence, we used this technique in this case.

Pigment recurrence post-treatment is common and has occurred within 24 h to 8 years.[9] In the present case, we noted recurrence within 2 months and it increased by 5 months. Dummett and Bolden noticed repigmentation as early as 33 days. They noticed 100% repigmentation in dark complexion individuals.[11] Our patient was dark complexioned and, hence, she was well appraised of possible recurrence prior to the treatment. Even though the pigmentation recurred, the intensity was less and gingival aesthetics was satisfactory. The gingival pigmentation score decreased from ’3’ to ’2’ as per the GPI. A similar study by Kaur et al. reported a decrease in the hyperpigmentation score decreased from 2.40 to 0.93 using the Dummett–Gupta oral pigmentation index.[12]

The mechanism of repigmentation is unclear. One hypothesis suggests that the melanocytes from the adjacent pigmented tissues migrate to the treated area and cause repigmentation.[13] Despite repigmentation, the treatment showed satisfactory results. The follow-up period was short (5 months) and the patient did not opt for orthodontic or restorative treatment options, which could have enhanced over all aesthetic results. Well-controlled, randomized clinical trials to focus on factors affecting the rate and frequency of repigmentation and the methods to prevent recurrence are required. Until the depigmentation, procedures should be performed in the cases of hyperpigmentation to improve aesthetics.

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
[PUBMED]    
2.
Dummett CO. Physiologic pigmentation of the oral and cutaneous tissues in the Negro. J Dent Res 1946;25:421-32.  Back to cited text no. 2
[PUBMED]    
3.
Rakhewar PS, Patil HP, Thorat M. Identification of gingival pigmentation patterns and its correlation with skin color, gender and gingival phenotype in an Indian population. Indian J Multidiscip Dent 2016;6:87-92.  Back to cited text no. 3
  [Full text]  
4.
Stokowski RP, Pant PV, Dadd T, Fereday A, Hinds DA, Jarman C et al. A genomewide association study of skin pigmentation in a South Asian population. Am J Hum Genet 2007;81:1119-32.  Back to cited text no. 4
    
5.
El Shenawy HM, Nasry SA, Zaky AA, Quriba MA. Treatment of gingival hyperpigmentation by diode laser for esthetical purposes. Open Access Maced J Med Sci 2015;3:447-54.  Back to cited text no. 5
[PUBMED]    
6.
Hoexter DL. Periodontal aesthetics to enhance a smile. Dent Today 1999;18:78-81.  Back to cited text no. 6
    
7.
Prasad D, Sunil S, Mishra R, Sheshadri. Treatment of gingival pigmentation: A case series. Indian J Dent Res 2005;16:171-6.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Rossi R, Brunelli G, Piras V, Pilloni A. Altered passive eruption and familial trait: A preliminary investigation. Int J Dent 2014;2014:874092. doi: 10.1155/2014/874092  Back to cited text no. 8
[PUBMED]    
9.
Patil KP, Joshi V, Waghmode V, Kanakdande V. Gingival depigmentation: A split mouth comparative study between scalpel and cryosurgery. Contemp Clin Dent 2015;6:S97-101. doi: 10.4103/0976-237X.152964.  Back to cited text no. 9
[PUBMED]    
10.
Cicek 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. 10
    
11.
Dummett CO, Bolden TE. Post-surgical clinical repigmentation of the gingivae. J Oral Surg Oral Med Oral Path 1963;16:353-65.  Back to cited text no. 11
    
12.
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. doi: 10.4103/0972-124X.70828.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.  Back to cited text no. 13
[PUBMED]    


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