|Year : 2016 | Volume
| Issue : 2 | Page : 87-92
Identification of gingival pigmentation patterns and its correlation with skin color, gender and gingival phenotype in an Indian population
Purshottam S Rakhewar, Harshal Pradip Patil, Manojkumar Thorat
Department of Periodontology, SMBT Dental College and Hospital, Sangamner, Maharashtra, India
|Date of Web Publication||6-Jan-2017|
Harshal Pradip Patil
Department of Periodontology, SMBT Dental College and Hospital, Sangamner - 422 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Objectives: Esthetics and smile-enhancing treatments have become an integral part of the dentistry; people always consult with periodontist for obtaining acceptable gingival esthetics. In smile designing esthetics, the color of gingiva has a major role. Although there is no any gold standard technique for managing melanin hyperpigmentation, esthetic concerns have lead increasing awareness about different depigmentation procedures. The aim of this study is to identify gingival melanin pigmentation patterns and to investigate its relationship based on clinical analysis with skin color, gender and gingival phenotype for various treatment modalities.
Methods: In total, 200 subjects without any systemic disease (100 males and 100 females with mean age 26.5 years) screened by a single person and categorized them by skin color as fair, wheatish, brown, and dark to identify the different distribution patterns of gingival melanin pigmentation anatomically. Along with this severity of melanin pigmentation and gingival phenotypes were assessed. By using a Chi-square test correlations of variables were checked.
Results: A positive statistical correlation was noticed between severity of gingival pigmentation and skin color. Dark-skinned subjects had heavy gingival pigmentation. The majority of population had pigmentation in attached gingiva and interdental papillae.
Conclusion: Within the limits of the present study, the majority of population showed a positive correlation with their skin color and the severity of melanin pigmentation.
Keywords: Gingival phenotype; gingival pigmentation; Indian; melanin pigmentation; skin color
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2016 [cited 2019 Jan 17];6:87-92. Available from: http://www.ijmdent.com/text.asp?2016/6/2/87/197763
| Introduction|| |
The gingiva covers the alveolar processes and surrounds the necks of the teeth.  The ideal color of normal gingiva is pink (salmon or coral pink). The color of normal gingiva varies due to intensity of melanin pigmentation which is more pronounced in blacks and Asians compared to Caucasians.  Oral pigmentations may be physiologic or pathologic, and it occurs in all human races and all nationalities. Normal color of gingiva is contributed by different types of pigments such as melanoid, carotene, reduced hemoglobin, soft keratin, and oxyhemoglobin. Out of this melanin pigmentation is the most common color variation often seen in gingival tissue. Dummett reported the occurrence of oral pigmentation as gingival tissues 60%, hard palate 61%, mucous membrane 22%, and tongue 15%.  Gingival hyperpigmentation is due to excessive melanin deposition by the melanocytes which mainly locate in the basal and suprabasal cell layers of the epithelium.  Pigmentation may be of a localized anomaly of limited significance or of multisystem diseases.  The severity of melanin pigmentation depends on a variety of factors mostly the megaloblastic activity and varies person to person.  Indian population have various color shades from fair to dark.  Ponnaiyan et al. study on South Indians showed pigmentation was maximum in attached gingiva and interdental papilla with positive correlation with skin color.
Although gingival hyperpigmentation is not any disease, it can be an esthetic problem for a subject with gummy smile.  Because of this, people with hyperpigmentation demand for depigmentation therapy. For better treatment strategies understanding the distribution patterns of pigmentation is very important. However, very limited data are available in the literature regarding the distribution patterns of gingival pigmentation and its severity in an Indian population. The present study was conducted to identify the different distribution patterns of gingival melanin pigmentation and to find out the correlation between skin color, gender, severity of melanin pigmentation, and the gingival phenotype.
| Methods|| |
The present study was conducted in the outpatient department of SMBT Dental College and Hospital, India for a month. The study was approved by Institutional Ethical Committee of SMBT Dental College. In total, 200 healthy controls with mean age 26.5 years (age group: 15-40 years) were included. Subject was selected by simple randomization method. The sample size was determined by a formula where P = 65%, for 5% level of significance Z 2α/2 = 1.96.
After explaining the purpose of study, informed consent was obtained from all subjects. A clinical examination of gingiva was performed by a single trained examiner to identify the different anatomic distribution patterns of gingival pigmentation, severity of gingival pigmentation, and gingival phenotype. The skin color was visually examined by comparing with shade guide and divided into 4 categories (fair, wheatish, brown, and dark).  Subjects having uniformly pigmented and nonmottled gingiva was included. Patients were excluded if they had chemical skin toning, albinism, mixed racial skin, periodontitis or any gingival pathology; drug or chemical pigmentation, mottling, and subgingival restorations.
Examination of gingival pigmentation and skin color
By using a Dummett's Oral Pigmentation Index  evaluation of the intensity of physiologic gingival pigmentation was carried out. The scoring pattern is like:
- 0 = Pink tissue (no clinical pigmentation)
- 1 = Mild, light brown tissue (mild clinical pigmentation)
- 2 = Medium brown or mixed pink or brown tissue (moderate clinical pigmentation)
- 3 = Deep brown or blue/black tissue (heavy clinical pigmentation).
Oral pigmentation was considered darker with higher the score. One investigator was tested for normal color vision. Intraoral photographs were obtained using a digital camera (Canon EOS 600D Taiwan). On computer display, the distribution patterns of gingival pigmentation were examined in anterior and posterior region. Under natural light visual examination of inner aspect of upper arm (less exposed to ultraviolet rays) was carried out and comparing it with shade guide, subjects were categorized into 4 categories as fair, wheatish, brown, and dark. The pigmentations patterns according to anatomic location were recorded. The gingival phenotypes were categorized as thick and thin based on visibility of periodontal probe after inserting into the sulcus.  Single trained person carried out all these examinations.
Chi-square test was performed using GraphPad Prism version 5.00 for Windows, (GraphPad Software, San Diego California USA), www.graphpad.com and correlations of variables were checked.
| Results|| |
After complete examination, patterns of anatomic distribution of gingival pigmentation were grouped into 7 classes such as Class I-no pigmentation [Figure 1], Class II-pigmentation in marginal gingiva only [Figure 2], Class III-pigmentation in interdental papillae only [Figure 3], Class IV-pigmentation in attached gingiva only [Figure 4], Class V-pigmentation in marginal gingiva and interdental papillae [Figure 5], Class VI-pigmentation in attached gingiva and interdental papillae [Figure 6], and Class VII-diffuse pigmentation involving all parts of gingiva [Figure 7]. It was noted that least pigmentation was observed in marginal gingiva alone (Class II) and more in the attached gingiva and interdental papillae (Class VI) [Figure 8]. The majority of subjects had wheatish (46%), brown (39%), and fair (9%) complexions and least with dark skin color (6%). The positive correlation was observed along skin color and intensity of gingival pigmentation. Skin color correlated with severity of gingival melanin pigmentation which was highly significant [Table 1]. Wheatish subjects had mild (23%) to moderate (15%) gingival pigmentation, fair subjects had mild gingival pigmentation (3%) whereas dark subjects had moderate (2%) to heavy pigmentation (3%); [Figure 9]. There were no significant correlations observed between genders, pigmentation patterns, phenotypes, and severity of pigmentation. Although 52% and 48% of subjects had thick and thin phenotype, respectively [Table 2] and [Table 3].
|Figure 5: Class V - pigmentation in marginal gingiva and interdental papillae|
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|Figure 6: Class VI - pigmentation in attached gingiva and interdental papillae|
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|Figure 7: Class VII - diffuse pigmentation involving all parts of gingiva|
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|Figure 9: Correlation of skin color with intensity of gingival pigmentation|
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|Table 1: Correlation between skin color and intensity of gingival pigmentation |
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|Table 2: Correlation between gender and distribution of gingival pigmentation |
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|Table 3: Correlation of phenotype of gingiva and intensity of pigmentation |
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| Discussion|| |
Gingival hyperpigmentation is a condition of major concern, and many patients confronted to the periodontist with the unaesthetic problem of dark gingiva which is genetically present in some population called as physiologic or racial pigmentation. In the present study, seven pigmentation patterns were identified. Majority of the subjects had pigmentation in the attached gingiva and interdental papillae (Class VI) which agrees with study done on South Indian population  which is in contrast to an Israeli Jewish population study  and South African Bantu population study  where they observed attached gingiva and interdental papillae only to be the most common pigmented sites respectively which may be due to the race wise variations. Furthermore, color of gingiva and facial complexion showed a positive correlation. Dark subjects observed with heavy gingival pigmentation and fair subjects with mild pigmentation in agreement with a study on the Indian population.  Thus, skin color can predict mucosal and gingival pigmentation. The study population in the present study comprised an equal number of males and females, which enabled comparisons with regards to gender. There was no significant correlation observed between gingival pigmentation patterns and gender which is in agreement with the previous studies in other races. , Furthermore, the correlation between severity of pigmentation and gingival phenotype was nonsignificant. The present study considered one more criteria of no gingival pigmentation at all (class I) which was not considered in the previous study carried out by Ponnaiyan et al. and patterns are classified based on increasing intensity and number of anatomic parts of gingiva involved. 
Nowadays demand for gingival depigmentation therapy is common and various different methods such as scalpel method, , Gingivectomy,  gingivectomy with free gingival autografting,  acellular dermal matrix allografting,  electrosurgery,  cryosurgery,  chemical agents like 90% phenol and 95% alcohol,  abrasion with diamond bur,  neodymium-doped: yttrium aluminum garnet (YAG) laser,  erbium-doped: YAG lasers,  semiconductor diode laser,  and CO 2 laser  have been used. Gingival recession, injury to underlying periosteum and bone, delayed wound healing, and loss of healthy enamel are common disadvantages by these procedures that's why should be performed carefully especially when phenotype is thin. If gingival phenotype is thick for depigmentation procedure, we can use gingivectomy by scalpel, abrasive technique, laser, cryosurgery, electrosurgery, chemical depigmentation. If phenotype is thin, there will be more chances of getting marginal tissue recession after depigmentation procedures and we can go for gingivectomy with free gingival grafting, acellular dermal matrix allograft or chemical depigmentation. Out of these various treatment modalities, cryosurgery, electrosurgery, and laser depigmentation showed least recurrence of pigmentations than bur abrasion and scalpel technique.  That's why in dark subject bur abrasion and scalpel technique should be used with caution where recurrence rate is maximum due to increased intrinsic melanogenesis compare to fairs. 
Considering the above observations of the gingival pigmentation with their distribution patterns, intensity, biotype, and correlation with gender and skin color; future controlled-multicenter and large sample study should be carried out to generalize these observations in the population.
| Conclusion|| |
It can be concluded from our present study that there is the presence of seven different pigmentation patterns among the Indian population. The majority of population have pigmentation in attached gingiva and interdental papillae (Type VI) with positive correlation between intensity of pigmentation and facial complexion. No male and female predilection observed. Gingival phenotype is not associated with severity of pigmentation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Carranza, Fermin A, Michael G Newman, Henry Takei. Carranza's Clinical Periodontology. 10 th
ed. St. Louis, Mo.: Elsevier Saunders; 2006. Print.
Hassell TM. Tissues and cells of the periodontium. Periodontol 2000 1993;3:9-38.
Dummett CO. Physiologic pigmentation of the oral and cutaneous tissues in the Negro. J Dent Res 1946;25:421-32.
Martini FH, Timmons MJ. Human Anatomy. Upper Saddle River, New Jersey: Prentice Hall Pub. Co.; 1995. p. 88-93.
Shafer WG, Hine MK, Levy BM. Text Book of Oral Pathology. Philadelphia: WB Saunders Co.; 1984. p. 89-136.
Cockings JM, Savage NW. Minocycline and oral pigmentation. Aust Dent J 1998;43:14-6.
Hourblin V, Nouveau S, Roy N, de Lacharrière O. Skin complexion and pigmentary disorders in facial skin of 1204 women in 4 Indian cities. Indian J Dermatol Venereol Leprol 2014;80:395-401.
Hoexter DL. Periodontal aesthetics to enhance a smile. Dent Today 1999;18:78-81.
Jahangiri L, Reinhardt SB, Mehra RV, Matheson PB. Relationship between tooth shade value and skin color: An observational study. J Prosthet Dent 2002;87:149-52.
Dummett CO, Gupta OP. The DOPI assessment in gingival pigmentation. J Dent Res 1966;45:122.
Cuny-Houchmand M, Renaudin S, Leroul M, Planche L, Guehennec L, Soueidan A. Gingival biotype: The probe test utility. Open J Stomatol 2013;3:123-7.
Ponnaiyan D, Jegadeesan V, Perumal G, Anusha A. Correlating skin color with gingival pigmentation patterns in South Indians - A cross sectional study. Oral Health Dent Manag 2014;13:132-6.
Gorsky M, Buchner A, Fundoianu-Dayan D, Aviv I. Physiologic pigmentation of the gingiva in Israeli Jews of different ethnic origin. Oral Surg Oral Med Oral Pathol 1984;58:506-9.
van Wyk CW. Mouth pigmentation patterns in a group of healthy South African Bantu. S Afr Med J 1970;44:177-80.
Raut RB, Baretto MA, Mehta FS, Sanjana MK, Shourie KL. Gingival pigmentation: Its incidence amongst the Indian adults. J Am Dent Assoc 1954;26:9-10.
Brown T. Oral pigmentation in the Aborigines of Kalumburu, North-West Australia. Arch Oral Biol 1964;9:555-64.
Steigmann S. The relationship between physiologic pigmentation of the skin and oral mucosa in Yemenite Jews. Oral Surg Oral Med Oral Pathol 1965;19:32-8.
Almas K, Sadig W. Surgical treatment of melanin-pigmented gingiva: An esthetic approach. Indian J Dent Res 2002;13:70-3.
Bergamaschi O, Kon S, Doine AI, Ruben MP. Melanin repigmentation after gingivectomy: A 5-year clinical and transmission electron microscopic study in humans. Int J Periodontics Restorative Dent 1993;13:85-92.
Dummett CO, Bolden TE. Postsurgical clinical repigmentation of the gingiva. Oral Surg Oral Med Oral Pathol 1963;16:353-65.
Tamizi M, Taheri M. Treatment of severe physiologic gingival pigmentation with free gingival autograft. Quintessence Int 1996;27:555-8.
Pontes AE, Pontes CC, Souza SL, Novaes AB Jr., Grisi MF, Taba M Jr. 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;18:135-43.
Gnanasekhar JD, Al-Duwairi YS. Electrosurgery in dentistry. Quintessence Int 1998;29:649-54.
Yeh CJ. Cryosurgical treatment of melanin-pigmented gingiva. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:660-3.
Hasegawa A, Okagi H. Removing melagenous pigmentation using 90 percent phenol with 95 percent alcohol. Dent Outlook 1973;42:673-6.
Sameer AM. Management of gingival hyperpigmentation by surgical abrasion: Report of three cases. Saudi Dent J 2006;18:162-6.
Atsawasuwan P, Greethong K, Nimmanon V. Treatment of gingival hyperpigmentation for esthetic purposes by Nd: YAG laser: Report of 4 cases. J Periodontol 2000;71:315-21.
Tal H, Oegiesser D, Tal M. Gingival depigmentation by erbium: YAG laser: Clinical observations and patient responses. J Periodontol 2003;74:1660-7.
Yousuf A, Hossain M, Nakamura Y, Yamada Y, Kinoshita J, Matsumoto K. Removal of gingival melanin pigmentation with the semiconductor diode laser: A case report. J Clin Laser Med Surg 2009;18:263-6.
Ozbayrak S, Dumlu A, Ercalik-Yalcinkaya S. Treatment of melanin-pigmented gingiva and oral mucosa by CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:14-5.
Lin YH, Tu YK, Lu CT, Chung WC, Huang CF, Huang MS, et al.
Systematic review of treatment modalities for gingival depigmentation: A random-effects poisson regression analysis. J Esthet Restor Dent 2014;26:162-78.
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.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3]