Treatment of gingival hyperpigmentation with rotary abrasive, scalpel, and laser techniques: A case series

Abstract

Melanin pigmentation often occurs in the gingiva as a result of an abnormal deposition of melanin, due to which the gums may appear black, but the principles, techniques, and management of the problems associated with gingival melanin pigmentation are still not fully established. Depigmentation procedures such as scalpel surgery, gingivectomy with free gingival autografting, electrosurgery, cryosurgery, chemical agents such as 90% phenol and 95% alcohol, abrasion with diamond bur, Nd: YAG laser, semiconductor diode laser, and CO₂ laser have been employed for removal of melanin hyper pigmentation. The following case series describes three different surgical depigmentation techniques: scalpel surgery, abrasion with rotary abrasive, and a diode laser. Better results of depigmentation were achieved with diode laser than conventional scalpel and with rotary abrasion with respect to esthetics. The results point out that lasers are an effective and a safe means to removal of hyperpigmentation from the gingiva. Healing was uneventful and no repigmentation occurred.

INTRODUCTION

Oral pigmentation is a discoloration of the gingival/oral mucosa, associated with several exogenous and endogenous factors. Etiological factors are varied which include drugs, heavy metals, genetics, endocrine disturbances, syndromes as Albright's syndrome, Peutz Jegher's syndrome, and also in inflammation. Adverse habits such as smoking can also stimulate melanin pigmentation and the intensity of pigmentation is related to the duration of smoking and the number of cigarettes consumed. The pigmentation is mostly localized at the anterior labial gingiva, affecting females more than males.[1]

Melanin, a nonhemoglobin-derived brown pigment, is the most common of the endogenous pigments and is produced by melanocytes present in the basal layer of the epithelium. Gingival hyperpigmentation is caused by excessive deposition of melanin located in the basal and suprabasal cell layers of the epithelium. Melanin pigmentation is the result of melanin granules produced by melanoblasts intertwined between epithelial cells at the basal layer of the gingival epithelium. The degree of pigmentation varies from one person to another and depends on variety of factors especially the melanoblastic activity.[2]

Although melanin pigmentation of the gingiva is completely benign and does not present a medical problem, complaints of “black gums” are common, particularly in patients having a very high smile line (gummy smile).

Gingival depigmentation can be considered a periodontal plastic procedure whereby the gingival hyperpigmentation is removed by various techniques and the technique selection should primarily be based on clinical experiences and individual preferences with primary indication of demand for improved esthetics.

Different techniques for depigmentation include:[3,4]

1. Scalpel technique

2. Cryosurgery

3. Electrosurgery

4. Lasers - Nd: YAG laser, Er: YAG laser, CO₂ laser

5. Chemical methods including acoustic agents – not used nowadays

6. Method aimed at masking the pigmented gingival from less pigmented gingival areas

   1. Free gingival graft
   2. Acellular dermal matrix allograft

The present case series describes three simple and effective surgical depigmentation techniques - The scalpel technique, rotary abrasive technique, and a diode laser surgery – for gingival depigmentation, which have produced good results with patient satisfaction.

THERAPY PROTOCOL

Depigmentation with rotary acrylic abrasive

A 31-year-old male patient reported to the Department of Periodontics with the compliant of “black colored gums [Figure 1].” Oral examination revealed that she had deeply pigmented gingiva from right first premolar to left first premolar. The use of a rotary abrasive was planned to perform the depigmentation. The entire procedure was explained to the patient and written consent was obtained. A complete medical, family history, and blood investigations were carried out to rule out any contraindication for surgery.

Figure 1.

Preoperative – Rotary abrasive

Local anesthesia was infiltrated in the maxillary anterior region from premolar to premolar (Lignocaine with adrenaline in the ratio 1:100000 by weight). A high speed hand piece with an acrylic rotary abrasive was used to remove the pigmented layer [Figure 2]. Pressure was applied with sterile gauze soaked in local anesthetic agent to control hemorrhage during the procedure. After removing the entire pigmented epithelium along with a thin layer of connective tissue with the acrylic rotary abrasive, the exposed surface was irrigated with saline. While using the rotary tool, minimal pressure was applied with feather light brushing strokes and without holding it in one place. Care was taken to see that all remnants of the pigment layer were removed [Figure 3]. The surgical area was covered with a periodontal dressing [Figure 4]. Post-surgical 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. The patient was reviewed at the end of 1 week to be satisfactory [Figure 5]. The patient had no complaints of postoperative pain or sensitivity. At the end of 3 months, the gingiva appeared healthy and no repigmentation was seen [Figure 6]. The healing process was proceeding normally and patient did not report any discomfort.

Figure 2.

Perioperative – Rotary abrasive

Figure 3.

Postoperative – Rotary abrasive

Figure 4.

Coe pack placed – Rotary abrasiv

Figure 5.

1 week post-operative – Rotary abrasive

Figure 6.

3 months post-operative – Rotary abrasive

Depigmentation with laser

A 24-year-old male patient complaining of heavily pigmented gums visited the Department of Periodontics, Army College of Dental Sciences, Secunderabad. He complained of dark gums [Figure 7] and requested for any cosmetic treatment which would eventually enhance the aesthetics on smiling. His medical history was non-contributory. The hyperpigmentation was esthetically displeasing and laser-assisted depigmentation of the gingiva in the anterior region from canine to canine in the maxilla was planned. Topical anesthetic gel was applied to the surgical field. Special eye glasses were worn by the patient and the staff to fulfill with the FDA laser safety rules. The properly initiated tip of the diode laser unit (Picasso, AMD laser technologies, USA; wavelength 810 nm) angled at an external bevel of 45 degrees and at energy settings of 0.5-1.5 watts continuous wave (CW) was used with small brush like strokes back and forth with gradual progression deeper along the same initial laser incision to remove the tissue. A 400 μm strippable fiber was used with a power setting of 1.5 watts initially in pulsed wave mode (PW) set at 0.20 ms of pulse duration and 0.10 ms of pulse interval for the de-epithelialization procedure [Figure 8].

Figure 7.

Preoperative – LASER technique

Figure 8.

Perioperative – LASER technique

After removal of the overlying epithelial tissue, power setting was increased to 2 W to attain rapid ablation for removing the pigments present deep beneath the basement membrane and minimize the hemorrhage from the connective tissue [Figure 9]. During the procedure, any tissue tags left out after laser ablation were wiped with sterile gauze soaked in saline every 3-5 min and thorough inspection was done to confirm no pigmented areas were left out The surgical area was covered with a periodontal dressing [Figure 10]. The patient was prescribed analgesics for use when required and was discharged with necessary post-operative instructions. The patient was reviewed at 1 week and the post-operative healing was uneventful [Figure 11]. The patient was recalled after 1 month and 3 months for evaluation of any repigmentation [Figure 12]. There was no incidence of any repigmentation.

Figure 9.

Postoperative – LASER technique

Figure 10.

Coe pack placed – LASER techn

Figure 11.

1 week post-operative – LASER technique

Figure 12.

3 months post-operative – LASER technique

Depigmentation with the scalpel technique

A 27-year-old female patient visited the Department of Periodontics, Army College of Dental Sciences with the chief complaint of “black” colored gums [Figure 13]. Her oral examination revealed that she had deeply pigmented gingiva from right first premolar to left first premolar. The patient requested for any kind of esthetic treatment which could make her “black” colored gums look better. The depigmentation procedure with scalpel was planned accordingly. After administration of local anesthetic, a Bard Parker handle with a No. 15 blade was used to remove the pigmented layer [Figures 14 and 15]. Pressure was applied with sterile gauze soaked in local anesthetic agent to control hemorrhage during the procedure. The entire pigmented epithelium along with a thin layer of connective tissue with scalpel was removed. The exposed surface was irrigated with saline the surgical area was covered with a periodontal dressing [Figure 16]. Post-surgical instructions were given to the patient along with antibiotics (Amoxicillin 500 mg, three times daily for 5 days) and anti-inflammatory analgesics (Ibuprofen and Paracetamol three times daily for 3 days). The patient was advised to 0.2% chlorhexidine gluconate mouth wash 12^th hourly for 1 week. The patient was reviewed at the end of 1 week. The healing process was proceeding normally and it was quite uneventful on the surgical area. The patient was asked to continue the chlorhexidine mouth wash for another week. At the end of 1 month, re-epithelization was complete and healing was found to be satisfactory [Figure 17]. The patient had no complaints of post-operative pain or sensitivity. The gingiva appeared healthy and no repigmentation was observed at the end of 1 and 3 months [Figure 18].

Figure 13.

Preoperative – Scalpel technique

Figure 14.

Perioperative – Scalpel technique

Figure 15.

Depigmentation with the scalpel technique

Figure 16.

Coe pack placed – Scalpel technique

Figure 17.

1 week post-operative – Scalpel technique

Figure 18.

3 months post-operative – Scalpel technique

CLINICAL EVALUATION

Melanin pigmentation index (Takashi et al.)[5]

The degree of melanin pigmentation was determined by melanin pigmentation index [Figure 19] based on the following scoring system:

Figure 19.

Melanin pigmentation index

Score 0: No pigmentation

Score 1: Solitary unit(s) of pigmentation in papillary gingiva without extension between neighboring solitary units

Score 2: Formation of continuous ribbon extending from neighboring solitary units.

Visual analog scale

The visual analog scale (VAS) was used to evaluate the subjective pain level experienced by the patient. The VAS consisted of a horizontal line of 10 cm (100 mm) long, anchored at the left end by the descriptor “no pain” and at the right end by “unbearable pain”. The patient was asked to mark the severity of the pain. The distance of this point, in centimeters, from the left end of the scale was recorded and used as the VAS score: 0 = no pain; –3 = slight pain; 3.1–6 = moderate pain; 6.1–10 = severe pain.

Wound healing

Wound healing was evaluated based on the following scores: A. Complete epithelization, B. Incomplete epithelization, C. Ulcer, D. Tissue defect or necrosis.

RESULTS

Because the patient was under anesthesia, evaluation of pain was done 1 day postoperatively. Healing was uneventful in 1^st week with pink color comparable to nearby non-treated area, resulting in a significant improvement in esthetic appearance. Patient's acceptance of the procedure was good and results were excellent as perceived by the patient. Compared to scalpel blade and rotary abrasion depigmentation, diode laser showed delayed healing [Table 1]. At the VAS evaluation sites operated on with scalpel blade and bur abrasion, the patient complained of moderate pain, but at the site treated with diode laser, only slight or no pain was recorded. However, the pain had reduced considerably 1 week after the surgery [Table 2]. The MPI score also showed that there was no recurrence of pigmentation at 3 months.

Table 1.

Clinical evaluation of wound healing

Table 2.

Clinical evaluation of pain visual analog scale and recurrence of pigmentation

DISCUSSION

Melanin pigmentation is frequently caused by melanin deposition by active melanocytes located mainly in the basal layer of the oral epithelium. Physiologic pigmentation is probably genetically determined, but as Dummet[6] suggested, the degree of pigmentation is partially related to mechanical, chemical, and physical stimulation.[7] Pigmentations can be removed for esthetic reasons. Different treatment modalities have been used for this aim.[8] The selection of a technique for depigmentation of the gingiva should be based on clinical experience, patient's affordability and individual preferences. There are increasing demands for cosmetic rehabilitation for gingival melanin pigmentation. Several modalities have been suggested for gingival depigmentation, varying from scalpel, electrosurgery, and cryosurgery to lasers.

Abrasion technique using a large round diamond bur in a high speed handpiece with copius irrigation also has been used but difficulty remains in controlling the depth of de-epithelization and obtaining an adequate access.

The semiconductor diode laser is emitted in continuous- wave or gated-pulsed modes, and is usually operated in a contact method using a flexible fiber optic delivery system. Laser light at 800 to 980 nm is poorly absorbed in water, but highly absorbed in hemoglobin and other pigments. Since the diode basically does not interact with dental hard tissues, the laser is an excellent soft tissue surgical laser, indicated for cutting and coagulating gingiva and oral mucosa, and for soft tissue curettage or sulcular debridement. The diode laser exhibits thermal effects using the “hot-tip” effect caused by heat accumulation at the end of the fiber, and produces a relatively thick coagulation layer on the treated surface. The usage is quite similar to electrocauterization. Tissue penetration of a diode laser is less than that of the Nd: YAG laser, while the rate of heat generation is higher.[9]

The advantages of diode lasers are the smaller size of the units as well as the lower financial costs. Diode laser did not produce any deleterious effect on the root surface. Thus, it is generally considered that diode laser surgery can be performed safely in close proximity to dental hard tissue. The healing period of scalpel wounds is shorter than with diode laser. However, scalpel surgery causes unpleasant bleeding during and after the operation and it is necessary to cover the exposed lamina propria with a periodontal pack for 7 to 10 days. The diode laser causes minimal damage to the periosteum and bone under the gingiva being treated, and it has the unique property of being able to remove a thin layer of epithelium cleanly. Although healing of laser wounds is slower than healing of scalpel wounds, a sterile inflammatory reaction occurs after laser use.[10]

Moritz et al. in an in vitro and in vivo study showed a bactericidal effect of diode laser. They found an extraordinarily high reduction of bacteria.[11] Blood vessels in the surrounding tissue up to a diameter of 0.5 mm are sealed; thus, the primary advantage is hemostasis and a relatively dry operating field.

The use of scalpel technique for the depigmentation is the most economical as compared to other techniques, which require more advanced armamentarium. However, scalpel surgery causes unpleasant bleeding during and after the operation, and it is necessary to cover the surgical site with periodontal dressing for 7 to 10 days.[12]

Electrosurgery has its own limitations in that its repeated and prolonged use induces heat accumulation and undesired tissue destruction.[13]

CONCLUSION

The need and demand for esthetics requires the removal of unsightly pigmented gingival areas to create a pleasant and confident smile, which altogether may alter the personality of an individual. This could be easily attained by using any of the methods described above. The application of diode laser appears to be a safe and effective alternative procedure for the treatment of gingival melanin pigmentation. Its benefits include ease of usage, effectiveness in the treatment of superficial benign pigmented lesions, convenience in dental clinics, and decreased trauma for the patient.