Depigmentation of the Gingivae
Updated: Mar 6, 2019
Excessive melanin in the gingival tissues can often cause dark spots or areas on the gums. Patients often find such an appearance unattractive and request cosmetic improvement of the gingival colour.
What are the treatment options? How can we deliver this? What are the consequences of such treatment?...
Melissa is one such patient who is unhappy with the appearance of her gums. She doesn't like their dark color and feels that they look "diseased". She otherwise has a natural smile which does tend to display some gingival tissues.
Identifying Gingival Pigmentation?
Firstly it is important to make an accurate diagnosis for "gingival hyperpigmentation". Increased pigmentation can occur in other clinical scenarios which must be ruled out such as:
Drug Induced Melanosis
Smoking Associated Melonosis
Endocrine Disordes (Addison's Disease or Cushings Syndrome)
Other Genetic Syndromes (Peutz-Jeghers, Albright's, Neurofibromatosis)
This list is not exhaustive. It is important to go through a detailed history and examination to exlude pathological etiology of the pigmentation. In most cases the visual appearance of the melanosis as well as patient's medical and ethnic history can be sufficient to conclude a diagnosis.
The identifying features for gingival hyperpigmentation includes:
Dark skin colour
Generalised and symmetrical
Non-contributory medical history
How Can We Treat Gingnival Hyperpigmentation?
"Depigmentation" of the gingivae can be done in a variety of ways. The most common and simplest technique employed is using a scalpel blade where the area of pigmentation is de-epithelialised.
We must first plan our surgery to identify the scope of our incisions. We can see here the areas which are planned for depigmentation marked by "X". Gingival margins are left alone so as not to damage the keratinised tissue quality in this area. Loss of keratinised tissue or thin tissue at the margins can lead to other problems (that discussion is for another day).
Depigmentation Surgical Procedure
We then take a blade and holding it paralel to the gingivae carefully de-epithelialise the tissues. We have to be careful to not remove excessive tissue so as to expose the bone while at the same time we must fully remove the epithelial layer. If some of the epithelial layer is remaining then melanocytes from that area will quickly proliferate and likely spread to recreate pigmented gingivae.
After administering a local infiltration, it is also advised to administer LA (with adrenaline) directly into the areas of de-epithelialilsation in order to assist in post operative hemostatic control.
Post Operative Healing after Depigmentation
The red, raw appearance which can "look" quite scary is surprisingly well tolerated by patients. Usual post operative instructions such as analgesia, maintaining good oral hygiene and warm salt/water mouthwashes is adequate to see the patient through. You have an option to cover the de-epithelialised layer with a periodontal dressing to improve patient comfort however retention of the material can be an issue.
The area starts to re-epithelialise fairly quickly within a few weeks. Healing is complete after 6 weeks and leads to an appearance in the picture below.
Are the Results Permanent?
Unfortunately it is possible for the gingivae to return to their original pigmentation over time. It is postulated that pigmented cells from near by tissues will travel to the gingival epithelium and start melanin deposition. This process can however take years. It is prudent to inform your patient that repeat procedures may be required to regain a pink color of the gingivae.
You can view our cases gallery to see the full pictures of this case and others.
Written by F Zaheer and pictures by K Hussain.