|Year : 2013 | Volume
| Issue : 2 | Page : 54-58
The correlation of skin color and gingival pigmentation patterns in a group of South Indians in Tamil Nadu, India
Deepa Ponnaiyan1, L Gomathy2, JA Anusha2
1 Senior Lecturer, Department of Periodontics, S.R.M. Dental College and Hospital, Chennai, Tamil Nadu, India
2 Final Year B.D.S Student, S.R.M Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||22-Oct-2013|
F4 Rajendra Apartments, 9 Babu Rajendra Prasad Street, West Mambalam, Chennai - 600 033, Tamil Nadu
Background: Melanin pigmentation of the gingiva occurs in all ethnicities. Excessive pigmentation is an esthetic concern that has increased awareness about depigmentation procedures. The purpose of the present study is to correlate skin color and gender with intensity and distribution of gingival melanin pigmentation in a group of South Indians for treatment strategies. Materials and Methods: A total of 200 male and female non-smoking healthy subjects were included aged 18-35 years. A clinical examination of gingiva was performed to assess the anatomic distribution of gingival pigmentation. The intensity of gingival pigmentation and phenotype of gingiva were also assessed. Subsequently, the skin color was visually examined and assessed as fair, wheatish brown and dark. Results: Six classes of gingival pigmentation were defined based on the anatomic distribution. Gingival pigmentation was observed as highest being in the attached gingiva and interdental papilla (25.4%) and least being in the marginal gingiva and interdental papilla (10.2%). Correlation between skin color and intensity of pigmentation was statistically significant, with dark skinned subjects having heavy gingival pigmentation. However, no correlation was found between gender and phenotype of the gingiva with intensity and distribution of pigmentation. Conclusion: South Indians predominantly have pigmentation in attached gingiva and interdental papilla and their skin color is positively correlated with the intensity of pigmentation. Incidence of pigmentation did not differ between the sexes. Majority of subjects had thick gingival phenotype. Anatomic delineation of gingival pigmentation and their contributory factors may help design treatment strategies in depigmentation procedures.
Keywords: Gingiva, gingival color, melanin, pigmentation, skin color, South Indians
|How to cite this article:|
Ponnaiyan D, Gomathy L, Anusha J A. The correlation of skin color and gingival pigmentation patterns in a group of South Indians in Tamil Nadu, India. SRM J Res Dent Sci 2013;4:54-8
|How to cite this URL:|
Ponnaiyan D, Gomathy L, Anusha J A. The correlation of skin color and gingival pigmentation patterns in a group of South Indians in Tamil Nadu, India. SRM J Res Dent Sci [serial online] 2013 [cited 2019 Sep 20];4:54-8. Available from: http://www.srmjrds.in/text.asp?2013/4/2/54/120178
| Introduction|| |
Melanin is the fundamental pigment that colors the tissues. It appears as early as 3 h after birth in the oral tissues and in some cases is the only sign of pigmentation on the body.  It is a non-hemoglobin-derived pigment formed by the cells called melanocytes, which are dendritic cells of neuroectodermal origin located in the basal and spinous layers of the gingival epithelium.  Melanin granules are phagocytosed and contained within other cells of the epithelium and connective tissue, called melanophages or melanophores.  It is generally accepted that pigmented areas are present only when melanin granules synthesized by melanocytes are transferred to keratinocytes. This close relationship between melanocytes and keratinocytes was labeled by Fitzpatrick and Breathnach as the epidermal-melanin unit. ,
The gingiva is the fibrous mucosa surrounding the teeth covering the coronal portion of the alveolar process.  The gingiva is the most frequently pigmented of the intra-oral tissues as well as the most readily seen. Dummet (1966)  queried the frequently used description of normal gingival as "coral pink" and suggested a more accurate statement of the pattern of normal pigmentation in the following definition. "The color of healthy gingiva varies from pale pink to bluish purple. Between these limits of normalcy are a large number of colors, which primarily depend on the intensity of the melanogenesis, degree of epithelial cornification, depth of epithelialization and the arrangement of gingival vascularity." Color variation may be uniform, unilateral, bilateral, mottled, macular or blotched. There are two basic color zones in the oral cavities of most people, which comprise the attached and marginal gingiva on one hand and the adjacent alveolar mucosa on the other hand.  Studying gingival color using the Munsell color system in dentistry, Ibusuki (1975)  reported that gingival color varied with the position of the papillary, marginal and attached gingiva. The color of the healthy gingiva is assumed to vary from pale pink and coral pink in Caucasians  to brown and blue black areas in Africans or Asians.  Indians more than any other ethnic group have a dramatic variation in their skin color. There are all shades ranging from fair to dark, which spans out over the entire country. It has been observed that there is a gradient from north to south of the Subcontinent with the North Indians close to European complexions and South Indian more closer to Sub-Saharan Africans.  Whether in South Indians this skin pigmentation is also evident in the oral cavity needs to be investigated.
Melanin hyperpigmentation of gingiva usually does not present as a medical problem, but many patients may consider their black gums to be unesthetic. This problem is aggravated in patients with a "gummy smile" or excessive gingival display while smiling.  Gingival depigmentation is a periodontal plastic surgical procedure whereby the gingival hyperpigmentation is removed or reduced by various techniques.  The foremost indication for depigmentation therapy is the demand by a person for improved esthetics. Understanding the distribution of pigmentation will help in devising better treatment strategies. However, the anatomic distribution of gingival pigmentation and its intensity have not been reported in South Indians in previous studies. Thus, the objective of the present study was to assess the distribution of physiologic gingival pigmentation, establish whether the correlation exists between skin color and gender with intensity of physiologic gingival pigmentation and gingival phenotype.
| Materials and Methods|| |
This correlation investigation study was carried out at the Department of Periodontics, S.R.M. Dental College and Hospital, Chennai, Tamil Nadu, India, for a period of 6 months. A total of 200 non-smoking subjects (100 males and 100 females) who fell within the age group of 18-35 years were included in the present study. An informed consent was obtained from all subjects after explaining the nature of the procedures, the objectives and possible discomforts and risks of the study to them. The study was approved by the ethical committee of S.R.M. University. The inclusion criteria were uniformly pigmented and non-mottled gingivae. The skin color must be distinctly fair, wheatish brown and dark, which is similar to the criteria adapted by Aina et al. (1978).  The exclusion criteria were patients with periodontitis or any gingival pathology, which might induce color changes; drug or chemical pigmentation and mottling. Others are chemical skin toning, albinism and mixed racial skin.
Evaluation of gingival pigmentation and skin color
The method used for intensity of physiologic gingival pigmentation evaluation in this study was the Dummett-Gupta Oral pigmentation Index (DOPI)  (Dummett and Gupta, 1966). This index represents the assignment of a composite numerical value to the total melanin pigmentation manifested on clinical examination of various oral tissues. The criteria are as follows:
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).
Higher the number; darker the oral pigmentation. One investigator was calibrated for the examination of the colors after been tested for normal color vision and color aptitude  using the line test, comparison of observers and of light sources with the use of a color rule.  The investigator was also seen to be adapted to daylight because higher intensity of light available from the day light sources may produce more color change. The observer views the specimen illuminated; hence, meeting the three conditions as highlighted by the International Commission on Illumination.  Wright (1974)  however stated that even after objective scientific evaluation, the eye is still the final judge of color.
To assess distribution patterns of pigmentation, oral photographs were obtained with a digital camera (Sony DSC-T700, Sony Electronics, San Diego, CA, USA) with standardized settings for grey, white and black and a centimeter scale with standard lighting and backdrop conditions. The photographs were reproduced in a computer display. These reproductions exhibited sizes similar to that of the actual mouth. The distribution of pigmentation was assessed in the anterior and posterior teeth in the entire anatomical areas of gingiva.
The skin colors were assessed by visual examination under natural light and were divided into four groups depending on the variations in skin color found in South Indians as fair, wheatish brown and dark.  Skin color was classified by comparing the color of the inner aspect of the upper arm, which is relatively unexposed to sunlight, with color photographs taken of similar areas of individuals who had previously been graded as fair skinned, wheatish brown and dark. The macroscopic distribution and color of the pigmentation of all surfaces were recorded in detail. Following this, the phenotype of gingiva was assessed by inserting the periodontal probe into the sulcus and assessing the visibility on the outer surface.  All examination was carried out by one single examiner. The phenotype was grouped as thick and thin. Pearson Chi-square test was applied to test the correlation of variables.
| Results|| |
Based on the evaluation of the subjects, a classification scheme describing the patterns of anatomic distribution of gingival pigmentation was formulated. The chart is presented in [Figure 1]. Six categories were defined. All subjects were subsequently allotted one of the categories. It was observed that pigmentation was more in the attached gingiva and interdental papilla (Class II) and least being in the marginal gingiva and interdental papilla together (Class VI) [Graph 1]. There were variations in the skin color and it was observed that the majority of subjects had wheatish (68%) and fair (67%) complexions with the least being dark skin color (21%). The correlation of skin color and intensity of gingival pigmentation according to DOPI was carried out and a positive correlation was observed. Skin color was in fact related to the intensity of pigmentation, which was highly significant (P = 0.00). It was observed that fair skin people had mild gingival pigmentation (18.5%), whereas dark skinned people had heavy pigmentation (10.5%) [Graph 2]. It was observed that there was no significant correlation between gender and distribution of gingival pigmentation (P = 0.373) [Table 1]. The correlation between gingival phenotype and intensity of gingival pigmentation was not significant (P = 0.125); however, it was observed that 68% of subjects had thick gingival phenotype [Table 2].
|Figure 1: Classification of gingival pigmentation pattern in South Indians|
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|Table 1: Correlation between gender and distribution of gingival pigmentation|
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|Table 2: Correlation of phenotype of the gingiva and intensity of pigmentation|
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| Discussion|| |
Gingival hyper pigmentation is seen as a genetic trait in some populations and is more appropriately termed physiologic or racial gingival pigmentation.  The prevalence of melanin pigmentation in different populations has been reported to vary between 0% and 89% with regard to ethnic factors and smoking habits.  In the present study, an attempt has been made to assess anatomic distribution of melanin pigmentation in the gingiva and also quantify it in a South Indian population, who have darker skin color owing to more melanin content and tend to have more oral pigmentation than their counterparts in North and Northeast India. This could be attributed to their genetic traits. 
The distribution of gingival pigmentation is quite unique in South Indians. In the present study, it was observed that the majority had pigmentation in the attached gingiva and interdental papilla (Class II). This finding was in contrast to a Jewish population study where they found attached gingiva only to be the most common pigmented anatomic division  and a South African population where pigmentation was most frequently seen in the interdental papilla.  This establishes the fact that there is racial variation in the pigmentation of the gingiva.
Extra oral tissue color (e.g., cheeks) appear to be an indication of the color of the gingiva and mucosa in about 85% of the cases. ,, The color of gingiva has been correlated with facial complexion in the present study and it was highly significant. It was observed that dark skinned subjects had heavy gingival pigmentation, whereas fair skinned subjects had mild pigmentation. These findings are similar to a previous study on an Indian population where incidence of pigmentation of the gingiva increases as the complexion changes to the darker shade.  It has been observed that in dark complexion people after surgical depigmentation the reappearance of pigmentation is more than people with fair complexion. This could be attributed to the increased intrinsic melanogenesis in dark complexion people.  Thus, skin color in fact can be a predictor for mucosal and gingival pigmentation.
There was no significant correlation of distribution pattern of gingival pigmentation and gender in the present study. This finding was similar to previous studies in other races. ,,,
In the present study, the phenotype of gingiva has been correlated with the intensity of gingival pigmentation, which has not been carried out in previous studies. It was seen that there was no significant correlation; however, the majority of subjects had thick phenotype. This finding was in contrast to previous studies carried out on Indians. This finding could be attributed to the fact that there is ethnic variation even within the same race for gingival phenotype. ,
| Conclusion|| |
Gingival pigmentation has become a major esthetic concern among patients today. In view of this depigmentation procedures have emerged as a mainstay of periodontal treatment. With the findings of the present study it can be concluded that:
Establishing a chart for the pattern of gingival pigmentation in South Indians will in future help in choosing a specific depigmentation therapy that will harmonize with skin color. This will enhance the esthetic result and level of satisfaction of the patient.
- In South Indians, there is a correlation between oral and cutaneous pigmentation, which was proved statistically beyond doubt.
- A relationship between the intensity of oral pigmentation and skin color was statistically established.
- The incidence of pigmentation did not differ between the sexes.
- There was no correlation between phenotype of the gingiva and intensity of gingival pigmentation; although, the majority of subjects had thick phenotype.
- Anatomic delineation of gingival pigmentation and their contributory factors may help design treatment strategies in depigmentation procedures specific for this population.
| Acknowledgments|| |
We would like to thank S.R.M. Dental College, Ramapuram, Chennai and S.R.M. University for supporting this study.
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[Table 1], [Table 2]