A 22-year-old nonsmoking patient of brown race was referred to the department of oral medicine and surgery at the University Dental Clinic of Monastir, with a chief complaint of a “dark-color upper gum.” He reported noticing darkening of the gums 10 years ago. The lesion was asymptomatic and has remained stable since then. He had no significant personal history and denied taking any medication or other substances that may have caused this pigmentation.\nIn clinical examination, periodontal tissues were healthy, but bilateral melanin pigmentation was present, associated with a fractured upper central incisor. A pigmentation index as mentioned by Kumar et al. [] was used to determine the level of pigmentation, and the score was diagnosed as “3” (diffuse brown to black pigmentation, marginal, and attached) ().\nAt first sight, the diagnoses evoked by this oral pigmentation of melanin were gingival pigmentation of exogenous origin (drugs, tobacco, metals,…), racial pigmentation, and Addison's disease. However, given the diffuse, bilateral appearance of these pigmentations which are not of recent appearance, the absence of smoking history or drug use, the patient's race, and the absence of systemic involvement, a final diagnosis of physiological gingival pigmentation (ethnic/racial) was established.\nFollowing the patient's request, a laser depigmentation procedure was planned after obtaining the patient's consent.\nA semiconductor diode surgical laser unit (Elexxion pico 808 nm diode laser, Elexxion AG, Singen, Germany) was used for the procedure; it is a digitally pulsed diode laser with a frequency of 20,000 Hz, a peak power of 5 W, and a pulse width of 26 microseconds. With this setting, the laser beam is “on” the tissue for only 26 microseconds which makes around one-third of the total cycle. The rest of the time is to allow the tissue to cool down. The semiconductor diode laser was operated in a contact method using a 400 nm flexible fiber optic handpiece.\nSpecial eyeglasses were worn by the patient and the staff to fulfill the Food and Drug Administration laser safety rules. After a local infiltration of anesthesia, the properly initiated tip of the diode laser was angled at an external bevel of 45 degrees. The melanin-pigmented gum was resected by circular movement of the fiber with a slight contact on the tissue, avoiding teeth structures.\nThis technique was performed on the entire pigmented anterosuperior attached gingiva for the deepithelialization procedure. Saline-soaked gauze was used to remove epithelial remnant. This procedure was repeated until the desired depth of tissue removal was reached, combined with a labial frenectomy (). The treatment time was two minutes compared to the ablative technique time up to 30 minutes in an area of first molar to first molar.\nAnalgesics and 0.2% chlorhexidine mouthwash were prescribed.\nThe patient did not report any postoperative pain, swelling, or other complications at the first and subsequent visits. It should be noted that a greyish-white fibrin layer completely covers the “laser wound” 6 hours after the operation (), which should not be misinterpreted as secondary infection. Four months later, the patient had no symptoms or signs of gingival melanin pigmentation ().
A 23-year-old male patient complaining of heavily pigmented gums [] visited department of Periodontics, Institute of Dental Studies and Technologies, Modinagar. On examination, the patient was otherwise healthy but had a deeply pigmented gingiva. Pigmentation was unsightly and hence laser depigmentation procedures were planned. The procedure was explained verbally to the patient and the consent was obtained.\nPatient and operating staff wore special diode-laser protective eye glasses. Highly reflective instruments or instruments with mirrored surfaces were avoided as there could be reflection of the laser beam. A semiconductor diode surgical laser unit (Sunny Gold; Mikro Scientific Instrument Pvt Ltd., India, wavelength 980 nm, power 2-4 W) was used for depigmentation of the maxillary and mandibular anterior gingiva up to the second premolar on both right and left sides. The semiconductor diode laser was emitted in gated-pulsed mode, and was operated in a contact method using a flexible fiber optic handpiece. The Laser settings used were: fluence between 5 and 15 J/cm2, pulse length between 20 and 50 ms, spot diameter of 2 mm and thermal relaxation times of 0.15 to 0.20 milliseconds. No topical or local anesthesia was given to patients. Laser ablation started from the mucogingival junction toward the free gingival margin, including papillae. The motion of ablation was circular with overlapping circles. High attention was taken to avoid passing the laser beam on teeth structures and over mucosa. During the procedure, laser ablated the gingival epithelial surface little by little to reach the pigments without causing any bleeding which was beneficial for clear visualization. [] To enhance visualization, normal saline-soaked cotton or gauze was used to remove epithelial remnant.\nThe ablation of the gingiva was completed within 20-25 minutes on the maxilla and mandible. Laser ablation of pigmented epithelium immediately produced a melanin pigment-free surface without any carbonization. The wound looked fresh with no bleeding []. There was no need to apply a periodontal dressing. Patient was instructed to avoid smoking and eating of hot and spicy foods for the first 24 hours and was discharged from dental office to perform normal daily activity. Healing was good at 1 month with pink color comparable to nearby non-treated area, resulting in a significant improvement in aesthetic appearance []. No infection or significant postoperative complications such as pain or bleeding were encountered. Fifteen months follow-up showed no signs of recurrence of pigmentaion.