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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 40  |  Issue : 1  |  Page : 23-28

Dermoscopic findings in benign racial gingival melanin hyperpigmentation and evaluation of its surgical management


1 Lecturer of Dermatology and Venereology Department, Faculty of Medicine, Tanta University, Egypt
2 Assistant Professor of Oral Medicine, Periodontology, Oral Diagnosis & Radiology Department, Faculty of Dentistry, Tanta University, Egypt

Date of Submission30-Jun-2019
Date of Acceptance18-Sep-2019
Date of Web Publication6-Jan-2020

Correspondence Address:
Soha Abdalla Hawwam
Lecturer of Dermatology and Venereology, Dermatology and Venereology Department, Faculty of Medicine, Tanta University Hospitals, El Geish Street, Tanta 31111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_33_19

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  Abstract 


Background Dermoscopic features of mucous membrane pigmented lesions are not the same as present in the skin. A major esthetic problem for a lot of people is gingival hyperpigmentation. Even though it is not a medical issue, a lot of methods are used in the treatment of this problem.
Objective To figure out dermoscopic patterns of benign racial gingival melanin hyperpigmentation and to assess the role of dermoscopic evaluation in its management.
Patients and methods A total of 20 patients were included in this study. Their age ranged from 23 to 30 years. They were selected for depigmentation procedures in the esthetic zone using a scalpel blade. Dermoscopic imaging and analysis of the patterns were done for all lesions. Clinical parameters were recorded. Recurrences of pigmentation were evaluated by clinical and dermoscopic examination at 4 weeks, 6 months, and 12 months postoperatively.
Results Dermoscopic features of benign racial gingival hyperpigmentation analyzed were dotted-globular pattern, pigment network pattern, fish scale-like pattern, and a hyphal pattern. All patients showed excellent gingival wound-healing response, with no adverse complications, and no repigmentation was observed.
Conclusion Dermoscopy is effective in diagnosis and evaluation of management of gingival melanin hyperpigmentation. Surgical gingival depigmentation is effective in esthetic treatment of gingival melanin hyperpigmentation.

Keywords: dermoscopy, gingival hyperpigmentation, surgical depigmentation


How to cite this article:
Hawwam SA, El-Makaky YM. Dermoscopic findings in benign racial gingival melanin hyperpigmentation and evaluation of its surgical management. Egypt J Dermatol Venerol 2020;40:23-8

How to cite this URL:
Hawwam SA, El-Makaky YM. Dermoscopic findings in benign racial gingival melanin hyperpigmentation and evaluation of its surgical management. Egypt J Dermatol Venerol [serial online] 2020 [cited 2020 Feb 20];40:23-8. Available from: http://www.ejdv.eg.net/text.asp?2020/40/1/23/275182




  Introduction Top


Morphologic features visibly not seen by naked eye are diagnosed by noninvasive dermoscope, which is used for detection of cutaneous melanoma early and examination of pigmented skin lesions [1]. Dermoscopy is also used for exclusion of oral mucous membranes or lip melanoma in doubtful cases, which may save patients from extensive and unnecessary surgery [2].

Despite increasing popularity in the examination of skin lesion, examination of mucous membrane lesions by dermoscope is less commonly used among health practitioners [2].

Several factors affect the mucosal color, including the number and melanogenic activity of the basal cell layer melanocytes of the epithelium, and also difference in melanosomal number and size. The melanin type, the heavily keratinized epithelium-masking effect, and the level of hemoglobin in the blood also cause mucosal coloring [3].

The pigmentation in oral mucosa naturally may be physiological or pathological. Multifocal or diffuse melanin pigmentation is characteristic clinically to physiological oral pigmentation. The most frequent pigmented intraoral site is gingiva [4].

Excessive melanin deposition is the main cause of benign racial gingival hyperpigmentation by the melanocytes located mainly in the basal and suprabasal layers of the epithelium [5].

Black gums owing to melanin hyperpigmentation are considered to be an esthetic problem to many patients rather than a medical problem, especially those with gummy smile, and this requires cosmetic therapy. Various methods have been used for cosmetic therapy such as gingivectomy, acellular dermal matrix allografts, electrosurgery, cryosurgery, abrasion with diamond bur, and various types of lasers [6].


  Aim Top


This study was designed to figure out the dermoscopic patterns of physiologic gingival melanin hyperpigmentation and to assess the applicability of dermoscopic evaluation in its surgical management.


  Patients and methods Top


This study included 20 patients (nine females and 11 males), with age range from 23 to 30 years. These patients attended the outpatient clinic, Faculty of Dentistry, Tanta University, for dermoscopic evaluation of gingival melanin pigmentation before and after surgical depigmentation.

Inclusion criteria

The following were the inclusion criteria:
  1. Systemically healthy participants with benign racial gingival melanin hyperpigmentation.
  2. Moderate to heavy melanin pigmentation in patient in the anterior gingiva from canine to canine (esthetic zone) according to Dummett oral pigmentation index for intensity of pigmentation [7].
    1. Gingiva is pink-colored with no clinical pigmentation.
    2. Mild clinical pigmentation (gingiva color is mild light brown color).
    3. Moderate clinical pigmentation (medium brown or mixed pink and brown color).
    4. Clinically heavy pigmentation (deep brown or bluish black color).
    5. Participants with score 1 or score 2 pigmentation in the esthetic zone according to melanin pigmentation index: for extent of pigmentation [8].
    6. Score 0: no pigmentation.
    7. Score 1: solitary unit(s) of pigmentation in papillary gingiva without extension between neighboring solitary units.
    8. Score 2: formation of continuous ribbon extending from neighboring solitary units.


Exclusion criteria

  1. Participants with any systemic diseases, especially those having healing problems, such as uncontrolled diabetes and auto-immune disease; tobacco smokers; pregnant women; and those with pathological gingival hyperpigmentation, including Addison’s disease, neurofibromatosis, oral melanotic maculae, oral mucosal melanoma, and drug-induced oral mucosal pigmentation were excluded.


Patients were given detailed information related to the purpose of the study before signing of the surgical release forms, and written informed consent for dermoscopic imaging was obtained from each patient; moreover, approval for this study was provided by medical ethics committee of Faculty of Medicine, Tanta University, Egypt.

Methods

Preoperative intraoral therapy and assessment

Complete medical, family history, and blood investigations were carried out to exclude any surgical contraindication and confirm the diagnosis of gingival pigmentation. Proper oral hygiene instructions were given to all patients. Thorough intraoral examinations were carried out for all patients.

Clinical photographs were taken for gingival pigmentation preoperatively, as shown in [Figure 1], using the same camera (Sony Cyber-shot DSC-W690 16.1 MP 10X optical zoom digital camera; Sony, Japan).
Figure 1 Preoperative clinical picture of gingival melanin hyperpigmentation.

Click here to view


Dermoscopic analysis

  1. Dermoscopic examination was carried out for all patients to confirm diagnosis of gingival pigmentation and to illustrate various patterns of pigmented oral lesions using 3 Gen Dermlite II pro HR (Dermlite, USA).
    1. All the lesions were analyzed for dermoscopic patterns.
    2. Each patient was scheduled for surgical removal of gingival pigmentation at anterior gingiva of at least one arch. Adequate local anesthesia was done, and the procedure was carried out from canine to canine region in the maxillary and/or mandibular anterior region.


Surgical procedures

  1. Two vertical incisions were placed demarcating the surgical area under local anesthetic infiltration.
  2. A split-thickness flap is elevated, and gentle dissection of the epithelium and a portion of the connective tissue out from one end of the vertical incision was done.
  3. Tear of the tissue, leaving of any pigmented posts behind, or bone exposure was avoided.
  4. Sterile gauze pressure pack was used to control bleeding, and periodontal pack was used to cover the surgical area for 1 week.
  5. Postoperative instructions were given.


Postoperative care

  1. Antibiotics, anti-inflammatory agents, and chlorhexidine mouthwash were used for 2 weeks.
  2. Follow-up of the patients was done every 2 weeks for healing observation during first 4 weeks following surgery then at 6 and 12 months.
  3. Dermoscopic evaluation of the pigmentation, as well as if there is any recurrence, was done postoperatively at 1 week, 4 weeks, 6 months, and 12 months after surgery.
  4. The following parameters were evaluated at 1 week, 4 weeks, and 6 months after surgery: (A) visual analog scale was used to assess intensity of pain experienced by the patient (0: no pain, 0.1–3.0: slight pain, 3.1–6.0: moderate pain, 6.1–10: severe pain), and (B) evaluation of gingival wound healing (0: tissue defect or necrosis, 1: ulcer, 2: incomplete or partial epithelialization, and 3: complete epithelialization).


Statistical analysis

Data were analyzed using SPSS software package, version 18.0 (SPSS, Chicago, Illinois, USA).


  Results Top


The results of this study revealed the following.

Demographic and clinical data of the patients

This study was performed on 20 patients, comprising nine females and 11 males, and their age ranged from 20 to 30 years. All patients were selected systematically free. Studied patients distributed according to demographic and clinical data showed no significant results.

Dermoscopic evaluation of the patients

Preoperative dermoscopic evaluation of the 20 patients for physiologic gingival melanin hyperpigmentation showed the following:
  1. Seven (35%) patients showed globules ([Figure 2]).
    Figure 2 Dermoscopic picture showing globules. Arrows pointing to lesions in figure.

    Click here to view
  2. Five (25%) patients showed pigment network ([Figure 3]).
    Figure 3 Dermoscopic picture showing pigment network. Arrows pointing to lesions in figure.

    Click here to view
  3. Three (15%) patients showed ring-like pattern ([Figure 4]).
    Figure 4 Dermoscopic picture showing arranged ring-like pattern. Arrows pointing to lesions in figure.

    Click here to view
  4. Three (15%) patients showed uniform arranged dots ([Figure 5]).
    Figure 5 Dermoscopic picture showing arranged dots pattern. Arrows pointing to lesions in figure.

    Click here to view
  5. Two (10%) patients showed scaly pattern ([Figure 6]).
    Figure 6 Dermoscopic picture showing scaly pattern. Arrows pointing to lesions in figure.

    Click here to view
    1. Dermoscopic postoperative evaluation at 4 weeks, 6 months, 12 months postoperatively showed complete absence of the pigmentation, with no recurrence ([Figure 7]).
      Figure 7 Clinical and dermoscopic picture after 12-month follow-up.

      Click here to view


Clinical Evaluation of the patients

  1. All patients attended the follow-up recall till the end of the study period (12 months). Patients were recalled on a weekly basis to observe healing in the first month postoperatively.
  2. Clinical intraoral examination postoperatively showed that in all patients, gingiva appeared healthy, and no repigmentation was observed.
  3. After 1 week, the pack was removed, and the surgical area examined. No postsurgical complications were encountered. The mean value of gingival wound healing at 1 week postoperatively was 2 (partial epithelialization).
  4. Wound healing in all patients was uneventful and showed excellent esthetics at 4 weeks, 6 months, and 12 months postoperatively, where the mean value of gingival wound healing was 3 (complete epithelialization).
  5. Visual analog scale at 1 week postoperatively was 1.8±2.69 (slight pain); however, it was decreased with time of evaluation, where it was 0 (no pain) at 4 weeks, 6 months, and 12 months postoperatively.


Evaluation of follow-up

There were no reported adverse effects in patients or recurrence or worsening of lesions during the follow-up period of 12 months.


  Discussion Top


Gingival melanin pigmentation causes esthetic concerns, and cosmetic therapy is becoming important for patients with this problem. Different treatment modalities have been used for this aim [6].

In the present study, 20 patients with benign racial gingival melanin hyperpigmentation were evaluated clinically and by dermoscopy and were subjected to scalpel surgical depigmentation for management of gingival hyperpigmentation.

In the current study, five dermoscopic patterns were detected in benign racial gingival melanin pigmentation in the form of globules, pigmented network, ring-like pattern, scale-like pattern, and dots. The most common patterns were globules and pigmented network in our patients, representing 60% of the cases.

The results of our study agreed with Lin et al. [9] who reported that benign pigmented lesions of mucous membrane frequently presented a dotted-globular pattern (25%), a homogeneous pattern (25%), a fish scale-like pattern (18.8%), and a hyphal pattern (18.8%). This study considered the fish scale-like pattern and hyphal pattern to be variants of the ring-like pattern.

Another study by Blum et al. [10] stated that dermoscopic features of mucous membrane lesions previously diagnosed histologically showed a pattern of dots, globules or clods, circles, and lines. Patterns consisted of pigmented lines were differentiated from reticular, parallel, and curved lines. If none of the basic elements was present (no dots, globules or clods, circles, or lines), the pattern was termed structureless.

Moreover, the results of our study agreed with Mannone et al. [11] who identified three major dermoscopic patterns in benign mucosal melanotic macule, known as parallel pattern often found in clinically typical melanocytic macules, structureless, predominantly found in clinically equivocal vulvar melanosis, with a blue hue pattern and reticular-like pattern associated with clinically equivocal melanosis.

The rationale for using scalpel surgical technique in this study was twofold: first, surgical excision performed with a blade was precise, definite, and under control, and second, with this technique, it was possible to appreciate the depigmented areas immediately and did not leave room for residual pigments.

In the present study, the procedure was carried out from canine to canine region in the maxillary and/or mandibular anterior region after adequate local anesthesia. In the present study, a periodontal pack was used cover the surgical area to minimize patient’s discomfort postoperatively, and this in agreement with Butchibabu et al. [12].

In the current study, gingival wound healing in all patients was uneventful, and in all patients, gingiva appeared healthy, and no repigmentation was observed up to 12 months; this is in accordance with Almas and Sadiq [13] who used scalpel surgical technique for depigmentation of gingival. Their study showed that after surgical technique, gingival healing was uneventful, patients’ acceptance of procedure was good and results were excellent, and there was no repigmentation up to 6 months. This is also in agreement with Nandakumar and Roshna [14] who performed plastic periodontal surgery combining gingival depigmentation with esthetic crown lengthening in a single appointment using scalpel surgical technique. Crown lengthening by external bevel gingivectomy was completed initially. The gingivectomy was followed by the depigmentation procedure using No. 11 scalpel blade; the entire pigmented epithelium along with a thin layer of connective tissue was removed (partial thickness flap). The surgical area healed well after 2 weeks. A 1-year follow-up demonstrated no repigmentation of the gingival. This is also in accordance with the observations of Antony and Khan [15] who observed that at the end of 1 month following gingival depigmentation using scalpel surgical technique, re-epithelialization was complete, and healing was found to be satisfactory. Patient had no complaints of postoperative pain or sensitivity. The gingiva appeared healthy, and no repigmentation was observed.


  Conclusion Top


Dermoscopy is very useful for evaluation of oral pigmentation and follow-up of its treatment and prognosis. It has to be emphasized that a major advantage of dermoscopy is the ability to exclude melanoma and avoid unnecessary excisional biopsies and extensive surgery, often resulting in significant disfigurement of face and oral cavity

In this study, five dermoscopic patterns were seen in benign racial gingival melanin pigmentation: globules, pigmented network, ring-like pattern, scale-like pattern, and dots. The most common patterns were globules and pigmented network.

The results have demonstrated that gingival depigmentation using scalpel technique seems to be effective in the esthetic treatment of gingival melanin hyperpigmentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol 2007; 57:84–95.  Back to cited text no. 1
    
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3.
Pai A, Prasad S, Patil BA, Dyasanoor S, Hedge S. Oral pigmentation: case report and review of malignant melanoma with flow charts for diagnosis and treatment. Gen Dent 2012; 60:410–416.  Back to cited text no. 3
    
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Tal H, Oegiesser D, Tal M. Gingival depigmentation by erbium:YAG laser: clinical observations and patient responses. J Periodontol 2003; 74:1660–1667.  Back to cited text no. 5
    
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Pontes AE, Pontes CC, Souza SL, Novaes ABJr, Grisi MF, Taba MJr. Evaluation of the efficacy of the acellular dermal matrix allograft with partial thickness flap in the elimination of gingival melanin pigmentation. A comparative clinical study with 12 months of follow up. J Esthet Restor Dent 2006; 18:135–143.  Back to cited text no. 6
    
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Dummett CO, Gupta OP. Estimating the epidemiology of oral pigmentation. J Natl Med Assoc 1964; 56:419–420.  Back to cited text no. 7
    
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Takashi H, Tanaka K, Ojima M, Yuuki K. Association of melanin pigmentation in the gingiva of children with parents who smoke. Pediatrics 2005; 116:e186–e190.  Back to cited text no. 8
    
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Lin J, Koga H, Saisa T. Dermoscopy of pigmented lesions on mucuocutaneous junction and mucous membrane. Br J Dermatol 2009; 1255–1261.  Back to cited text no. 9
    
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Blum A, Simionescu O, Argenziano G. Dermoscopy of pigmented lesions of the mucosaand the mucocutaneous junction. Arch Dermatol 2011; 47:1181–1187.  Back to cited text no. 10
    
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Mannone F, De Giorgi V, Cattaneo A, Maasi D, De Magnis A, Carli P. Dermoscopic features of mucosal melanosis. Dermatol Surg 2004; 30:1118–1123.  Back to cited text no. 11
    
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Butchibabu K, Koppolu P, Krishna Tupili M, Hussain W, Lakshmi Bolla V, Patakota K. Comparative evaluation of gingival depigmentation using a surgical blade and a diode laser. J Dent Lasers 2014; 1:20–25.  Back to cited text no. 12
    
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Almas K, Sadiq W. Surgical treatment of melanin- pigmented gingiva: an esthetic approach. Indian J Dent Res 2002; 13:70–73.  Back to cited text no. 13
    
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Nandakumar K, Roshna T. Anterior esthetic gingival depigmentation and crown lengthening. J Contemp Dent Pract 2005; 3:149–147.  Back to cited text no. 14
    
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Antony V, Khan R. Management of gingival hyperpigmentation − 2 case reports. J Dent Med Sci 2013; 4:20–22.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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