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 21-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with the complaint of discoloration in upper front teeth []. History of the patient revealed the presence of yellowish brown and white patches on teeth since childhood. Clinical examination showed the presence of dark yellow patches in maxillary central incisors and white patches on the facial surface of all teeth. Careful exploration of teeth revealed intact and smooth enamel surfaces. Several treatment options suggested to the patient were microabrasion, microabrasion along with bleaching, and direct or indirect veneers. Patient declined any procedure that included preparation of her intact tooth surfaces. After discussion, it was agreed to use enamel microabrasion followed by bleaching to improve the appearance of her teeth. The maxillary canines and incisors to be treated were first cleaned with pumice and water slurry. Petroleum jelly was applied around the cervical portion of the teeth to prevent leakage of the hydrochloric acid or damage to the gingiva. The teeth were then isolated using rubber dam. Freshly prepared solution of 11% hydrochloric acid was applied using cotton pellet on the discolored area followed by application of coarse composite contouring discs (Super Snap, Shofu Inc., Japan) at low speed for 10 seconds per tooth []. Same procedure was repeated 3 times at the same visit, which resulted in lightening of the dark areas to a great extent []. White spots were still evident on the labial surfaces of teeth. Thereafter, the remaining acid was rinsed from the teeth by use of gentle air water pressure and a high-volume aspirator. All teeth were finished using fine and extra fine grit abrasive discs (Super Snap). After finishing, the bleaching agent (XX-White™, DENT’N Co., France) was applied over the labial surfaces of isolated teeth, followed by light activation using a bleaching light (Flexi Light whitening system, DENT’N Co., France) for 4 minutes []. Bleaching procedure was repeated one more time for 8 minutes. The bleaching agent was removed by means of moist cotton followed by rinsing with air water spray. Lightening of the teeth shade was noted and rubber dam was removed. All the treated teeth were polished using fine polisher (Compo Site, Shofu Inc, Japan) to obtain high luster. High gloss finish obtained after fine polishing, camouflaged white spots as well as remaining dark areas on the enamel surface []. The patient was informed regarding the likelihood of developing dentinal hypersensitivity, which would subside in a few days. The patient was prescribed the calcium sodium phosphosilicate-containing desensitizing tooth paste (Vantej™, Dr. Reddy's Laboratories Ltd., India) for 3 weeks and then discharged. At 1 month follow-up, the results were stable and the patient did not complain of any symptoms related to dentinal hypersensitivity [].