Black Gums and Gingival Depigmentation

What Is Gingival Depigmentation?

Gingival depigmentation is one of the important components of esthetic dentistry, which aims to remove the melanotic pigmentation present in the gingiva. It employs almost every technique ranging from scalpel method to electrocautery. However, every effort is made to remove the epithelial lining of the gingiva, but sometimes there are chances of recurrence.

What Is Esthetic Dentistry?

When we talk of esthetic dentistry, we consider both teeth and gums since they are most visible during a healthy smile. Clinicians perform every esthetic procedure to improve the look of the teeth, but there are very few chances of improving the gums that make perfect harmony with the teeth. Esthetic dentistry is limited to modifications in shape and size, but it also aims to preserve the function and structure of the gingiva. The oral cavity encounters a lot of pigmentations, which are both physiological and pathological. Certain conditions like Addison’s disease and Peutz-Jeghers syndrome cause excessive pigmentation. These conditions require specific treatments by the use of long-term medications.

What Causes Black Gums?

1) Metal Deposition - Many metals get deposited in the form of sulfides or other salts in the oral cavity due to unintentional ingestion or direct exposure. These include cadmium, bismuth, arsenic, mercury, and lead. The deposition of these metals are fatal pathology and requires emergency treatment.

2) Melanin Pigmentation - Melanin pigmentation is not a pathological phenomenon. It is a physiological phenomenon that is characterized by blackish pigmentation in the skin and the gums. This melanin is secreted by melanocytes, which are released through melanophores and are digested by melanophages. The incidence of occurrence varies from:

• 61 % in the hard palate.

• 60 % in the gingiva.

• 10 % in the tongue.

What Are the Treatment Options for Melanin Pigmentation?

The removal of melanin pigmentation is employed by many dentists to provide esthetic looks. It includes the use of:

1. Scalpel method.

2. Cryosurgery.

3. Laser.

4. Electrocautery

5. Chemical methods.

6. Free gingival grafts.

7. Alloderm.

8. Radiosurgery.

9. Bur abrasion.

1) Scalpel Method:

It is the most commonly used method. It is performed under local anesthesia with the use of a scalpel.

Advantages-

• Less cost.

• Easy to perform.

• No need for any armamentarium.

Disadvantages-

• Chances of excessive postoperative bleeding.

• Chances of infection.

2) Cryosurgery:

This procedure employs the use of liquid nitrogen by cryoprobe and works on freezing the involved tissue.

Advantages-

• Does not require local anesthesia.

• No need for sutures.

Disadvantages-

• Excessive postoperative swelling.

• Excessive tissue destruction due to freezing of tissues.

3) Laser:

It employs different wavelengths ranging from 810 to 2940 nm. It involves the ablation of tissue by selective wavelength.

Advantages-

• Does not require sutures.

• Lesser chances of trauma to tissues.

Disadvantages-

• Delayed healing is one of the commonest side effects of lasers.

4) Chemical Methods:

Phenols and alcohol are also used in depigmentation.

Advantages-

• Easy application.

• Lack of local anesthesia.

Disadvantages-

• Cardiac Arrhythmias.

• Immediate burning sensation.

• Special care in kidney failure patients.

5) Electrosurgery:

It makes use of electric current through an electrode. Application of excessive heat causes the destruction of tissue.

Advantages-

• Less hemorrhage.

• Less scar formation.

Disadvantages-

• Because of excessive tissue destruction due to electric current, there is a foul smell which is sometimes uncomfortable to the patients.

6) Free Gingival Grafts:

It is an esthetic procedure. Free gingival graft employs the use of graft from the palate.

Advantages-

• Less reoccurrence.

Disadvantage-

• Painful postoperative wound.

• Limited donor tissue.

7) Alloderm:

Alloderm uses a membrane to cover the tissue.

Advantages-

• Better esthetics than free gingival graft.

Disadvantages-

• The cost factor is a major issue.

• Contraction of graft is also reported in some cases.

8) Radiosurgery:

It is the latest method developed for depigmentation. It uses radio frequencies in the form of an electrode and causes coagulation of tissues.

Advantages-

• Self-sterilizing in nature.

• Provides blood-less surgery.

• Good visibility.

Disadvantages-

• A foul smell makes the patient uncomfortable.

• It requires two sittings.

• Special precaution is required in cardiac pacemaker patients.

9) Bur Abrasion:

It involves the use of diamond bur with rotary instruments.

Advantages-

• Repetition can be done.

• Easy to perform.

Disadvantages-

• Enamel or bone loss due to excessive destruction.

• Uncontrolled bleeding.

How Is the Healing Process After Depigmentation?

Healing is one of the important phenomena. After the scalpel method, there is a need for periodontal dressing to cover the surgical area. It is observed that the newly attached gingiva is formed with minor scar tissue. Healing in cryosurgery is characterized by superficial necrosis accompanied by a white slough separated from the underlying tissue (pink colored). In electrosurgery, clot formation is the first step accompanied by necrosis and then replacement of granulation tissue. In laser, first, there is evidence of a yellow area that is removable in nature. It is followed by re-epithelialization. Healing of grafts is associated with degeneration followed by re-epithelialization and connective tissue formation. But in addition, a fibrous attachment also occurs.

What Is Re-Pigmentation?

The biggest problem we face after treating depigmentation is re-pigmentation. The reason attributed to re-pigmentation is the immigration of melanocytes from the nearby tissues. The time duration varies according to the cases. In some cases, it appears in 22 to 55 days, while in some cases, it may appear after one year. Cryosurgery cases were found to have re-pigmentation after 20 months, while lasers (especially carbon dioxide) showed re-pigmentation in two years. In the scalpel method, the time duration varied from 33 days to 7 years. Re-pigmentation was observed in chemical methods also, but there are some positive results too. It was observed that after the scalpel method, re-pigmentation was not observed after a long follow-up of 431 days. Some studies support ND: YAG (Neodymium-doped Yttrium Aluminum Garnet) laser, which showed no re-pigmentation after 180 days.

Conclusion:

Black gums due to melanin pigmentation are not a problem. But sometimes, especially in the case of a gummy smile, it is a great esthetic problem. So if clinicians are opting for this procedure, they should focus on the complete removal of melanocytes since the recurrence rate is high. The method should be done according to patient requirements, feasibility, and medical conditions. On the aspect of patients, I recommend regular follow-ups as per the clinician’s protocol.