Normal and Abnormal Normal and Abnormal Appearance of the Gingiva: Appearance of the Gingiva: Stippling and PigmentationStippling and Pigmentation

What is Stippling?

STIPPLINGSTIPPLING

Small depressions or “pits” in the Small depressions or “pits” in the epithelium of epithelium of healthy attached gingivahealthy attached gingiva (bound to underlying alveolar bone)(bound to underlying alveolar bone)

Has an orange-peel appearance. Has an orange-peel appearance. Consequence of rete pegs/ridges, which Consequence of rete pegs/ridges, which

are deep epithelial projections into the are deep epithelial projections into the underlying connective tissue. underlying connective tissue.

If the gingiva appears smooth, clinically, If the gingiva appears smooth, clinically, this does not neccesarily indicate this does not neccesarily indicate pathology.pathology.

STIPPLING in healthy STIPPLING in healthy gingivagingiva

How does Stippling appear How does Stippling appear ClinicallyClinically & & HistologicallyHistologically??

A= Stippling of A= Stippling of gingiva gingiva

B= Keratin layerB= Keratin layer

Stippled Appearance

Attached gingivaFree gingiva*

* Free gingiva is not stippled

Causes of Altered Stippled Causes of Altered Stippled GingivaGingiva

Any condition that Any condition that enlargesenlarges the attached the attached gingiva will cause gingiva will cause stippling to disappearstippling to disappear!!

Causes of Gingival Enlargement:Causes of Gingival Enlargement: InflammationInflammation (e.g. gingivitis) (e.g. gingivitis) Drug-inducedDrug-induced (e.g. Ca (e.g. Ca2+ 2+ channel blockers, channel blockers,

anticonvulsants)anticonvulsants) Conditioned enlargementConditioned enlargement (e.g., pregnancy, (e.g., pregnancy,

puberty, Vit C deficiency, pyogenic granulomas) puberty, Vit C deficiency, pyogenic granulomas) Systemic diseaseSystemic disease (e.g., leukemia, (e.g., leukemia,

granulomatous diseases, neoplasms)granulomatous diseases, neoplasms) Bony/dental Bony/dental tissue lesionstissue lesions

Examples of Gingival Examples of Gingival EnlargementEnlargement

GINGIVAL PIGMENTATIONGINGIVAL PIGMENTATION& Dark Patches& Dark Patches

Gingival PigmentationGingival Pigmentation

Gingival pigmentation results from Gingival pigmentation results from melanin granulesmelanin granules, which are produced , which are produced by melanoblasts. The degree of by melanoblasts. The degree of pigmentation depends on melanoblastic pigmentation depends on melanoblastic activity. activity.

Variations in gingival color may be Variations in gingival color may be correlated with the correlated with the racial diversityracial diversity of an of an individual or may be a reflection of individual or may be a reflection of pathologic influencespathologic influences..

How Does Gingival Colour How Does Gingival Colour Differ Between Races?Differ Between Races?

The colour of the gingiva generally matches The colour of the gingiva generally matches the skin colour of the person.the skin colour of the person.

High levels of oral melanin pigmentation are High levels of oral melanin pigmentation are normally observed in:normally observed in: Africans/decendants of Africans (gums appear Africans/decendants of Africans (gums appear

darkdark/close to black)/close to black) Hispanics (gums vary from light Hispanics (gums vary from light pinkpink to dark to dark brownbrown)) East Asians (gums appear coral East Asians (gums appear coral pinkpink to light to light brownbrown))

People with fair skin (Caucasians) will not People with fair skin (Caucasians) will not demonstrate overt tissue pigmentation; thus demonstrate overt tissue pigmentation; thus their gums appear their gums appear pinkpink..

HyperpigmentationHyperpigmentation Hyperpigmentation of the gingiva is caused Hyperpigmentation of the gingiva is caused

by by excessive melanin depositionexcessive melanin deposition by the by the melanocytesmelanocytes mainly located in the basal and mainly located in the basal and suprabasal cell layers of the epithelium.suprabasal cell layers of the epithelium.

Melanin increases with Melanin increases with exposure to the sunexposure to the sun; ; thus, individuals with darker complexions thus, individuals with darker complexions and those who spend a lot of time and those who spend a lot of time outdoorsoutdoors tend to have darker gums (e.g., children tend to have darker gums (e.g., children with a high smile line).with a high smile line).

Hyperpigmentation is observed in the Hyperpigmentation is observed in the gingiva closest to the teethgingiva closest to the teeth, often as dark , often as dark patches; the portion hidden under the lips patches; the portion hidden under the lips usually appear pink.usually appear pink.

How Does Hyperpigmentation How Does Hyperpigmentation Affect Individuals?Affect Individuals?

Hyperpigmentation is Hyperpigmentation is notnot commonly an commonly an indication of a indication of a medical problemmedical problem!!

It is considered a It is considered a genetic traitgenetic trait in some in some populations; medically, it is known as racial populations; medically, it is known as racial or physiological gingival pigmentation.or physiological gingival pigmentation.

The effects may be The effects may be esthetic problemsesthetic problems and and embarassment, especially if the embarassment, especially if the pigmentation is visible during speech and pigmentation is visible during speech and smiling.smiling.

What Can Be Done to Alter What Can Be Done to Alter Hyperpigmentation?Hyperpigmentation?

The gingiva can be de-pigmented!The gingiva can be de-pigmented! Yes, the “blackness” of the gums is Yes, the “blackness” of the gums is

superficial and can removed.superficial and can removed.

Removal of Dark PatchesRemoval of Dark Patches Various Various de-pigmentation techniquesde-pigmentation techniques can be can be

employed.employed. The most popular one is the The most popular one is the surgical removalsurgical removal

of the undesired pigmentation:of the undesired pigmentation: Done under local anesthesiaDone under local anesthesia Only the outer layer of gum Only the outer layer of gum epithelium is epithelium is

removedremoved, with a layer of the underlying connective , with a layer of the underlying connective tissue; healing via secondary intention is allowedtissue; healing via secondary intention is allowed

The new epithelium that forms is The new epithelium that forms is devoid of devoid of melaninmelanin

Immediate resultsImmediate results are evident on the day of the are evident on the day of the procedureprocedure

De-pigmentation of GingivaDe-pigmentation of Gingiva

Pathological Influences in Pathological Influences in Gingival PigmentationGingival Pigmentation

These include:These include: hypoadrenocorticism (Addison's disease)hypoadrenocorticism (Addison's disease) Nevi (pigmented birthmarks)Nevi (pigmented birthmarks) Depositions of heavy metals Depositions of heavy metals