|Year : 2015 | Volume
| Issue : 3 | Page : 211-213
Gingival vitiligo: A very rare clinical entity
Mundoor Manjunath Dayakar1, Jitendra Kumar1, Gurpur Prakash Pai1, Sonal Srivastava2
1 Department of Periodontics, KVG Dental College and Hospital, Sullia, Karnataka, India
2 Department of Oral Medicine and Radiology, KVG Dental College and Hospital, Sullia, Karnataka, India
|Date of Web Publication||4-Aug-2015|
Department of Periodontics, KVG Dental College and hospital, Sullia, Karnataka
Source of Support: None, Conflict of Interest: None
Vitiligo affecting the skin is commonly reported although rare cases have been reported regarding depigmented lesions of the oral cavity. On reviewing the literature, only few cases of gingival vitiligo or similar lesions have been reported till date and these lesions cause an esthetic challenge. Vitiligo has been defined as an acquired, slowly progressive loss of cutaneous pigment that occurs as irregular, sharply defined patches that may or may not be surrounded by macroscopic hyperpigmentation. Here, we are presenting a very rare case of vitiligo affecting only gingiva in which the patient was otherwise absolutely asymptomatic, and patient does not have white patch anywhere in skin except on gingiva.
Keywords: Esthetics, gingival vitiligo, tattooing therapy
|How to cite this article:|
Dayakar MM, Kumar J, Pai GP, Srivastava S. Gingival vitiligo: A very rare clinical entity. SRM J Res Dent Sci 2015;6:211-3
| Introduction|| |
In this modern era of world, everyone is concerned about cosmetic and appearance, and thus changes in the color of skin and mucosa cannot only cause cosmetic disfigurement but also affect the mental status of patients.  Vitiligo has been defined as an acquired, slowly progressive loss of cutaneous pigment that occurs as irregular, sharply defined patches which may be surrounded by macroscopic hyperpigmentation.  Vitiligo affecting oral tissues is very rare and is a matter of concern for individuals. Here, we are presenting a case of vitiligo affecting only gingiva in which the patient was otherwise absolutely asymptomatic.
Vitiligo affects approximately 0.1-4% of the general population and has no racial or regional tendency. A positive family history has been observed in vitiligo cases suggestive of a genetic association. Females are more commonly affected. 
| Case Report|| |
A 19-year-old male patient reported to our department of Periodontics with a chief complaint of deposits on tooth surface since 1-year that was associated with bad breath early morning. Patient was otherwise healthy and was not under any medication. And there was no history of alcohol consumption, smoking, and areca nut chewing habits. On examination, a white patches was seen on gums. On eliciting the history patient told that the lesion was present since 2 years and was asymptomatic. There was gradual increase in size in 1 st year and then it remained stable. Neither was there a familial history of similar disease nor a history of trauma in the concerned site.
On physical examination, the patient was moderately built and nourished. Extra oral examination revealed no abnormal findings, and there was no abnormality present anywhere else on the body. Intraorally, in the maxillary arch, there was well demarcated white patch of 2 cm × 2 cm involving gingiva extending from the middle of the right central incisor to the distal aspect of right canine anteroposteriorly from the attached gingiva to the mucogingival junction superoinferiorly [Figure 1]. A similar diffuse white patch of 2 cm × 2 cm was present on the maxillary gingiva extending from the distal half of the left maxillary central incisor to the distal half of left maxillary canine. Similar lesion was also present on attached gingiva of canine [Figure 1]. There was no other abnormality detected intraorally.
An incisional biopsy was obtained involving the white patch and the surrounding normal tissue from the interdental area between maxillary central incisor and lateral incisor region the section was stained with hematoxylin and eosin on microscopic examination of the tissue section under ×40 magnification it showed very mild pigmentation in the epithelium when compared to the tissue taken from the adjacent normal area that showed dense melanocytes. With number of melanocytes ranging from 0 to 2 in number per rete peg in the region of white patch [Figure 2] contrary to normal epithelium which showed 20-30 melanocytes per rete peg [Figure 3].
|Figure 2: Eosin and hematoxylin stained tissue section under ×40 magnifications in microscope shows melanocytes ranging from 0 to 2 in number per rete peg in the region of white patch|
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|Figure 3: Eosin and hematoxylin stained tissue section under ×40 magnifications in microscope shows normal epithelium that have 20-30 melanocytes per rete peg|
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Immunohistochemical staining by S-100
S-100 proteins are a family of low-molecular-weight proteins found in vertebrates and characterized by two calcium-binding sites that have helix-loop-helix ("EF-hand type") conformation. S-100 is normally present in cells derived from the neural crest (Schwann cells, and melanocytes), chondrocytes, adipocytes, myoepithelial cells, macrophages, Langerhans cells, dendritic cells, and keratinocytes. Several members of the S-100 protein family are useful as markers for certain tumors and epidermal differentiation. It can be found in melanomas,  100% of schwannomas, 100% of neurofibromas (weaker than schwannomas), 50% of malignant peripheral nerve sheath tumors (may be weak and/or focal), paraganglioma stromal cells, histiocytoma and clear cell sarcomas. Further, S-100 proteins are markers for inflammatory diseases and can mediate inflammation and act as antimicrobial.
| Discussion|| |
Term vitiligo has been derived from a Latin word "vitium" meaning defect.  Vitiligo is the most common hypopigmentary disorder that has been defined as partial or total loss of skin pigmentation, often in patches. It is an acquired disease that is characterized by loss of melanocytes.  Exact etiology is not known however destruction of melanocytes is considered to be the main cause. Various hypotheses have been postulated regarding this which includes autoimmune hypothesis, neural hypothesis, self-destructive hypothesis and biochemical hypothesis. According to autoimmune hypothesis destruction of melanocytes occurs because of antibodies formed against them whereas according to neural hypothesis melanocytes destruction occurs as a result of altered reaction of melanocytes toward neuropeptides. As the term only explains in self-destructive melanocytes themselves destroy as a protective mechanism against melanin precursors.  Biochemical hypothesis which assumes that over synthesis of hydriobiopterin, a cofactor of tyrosine hydroxylase, results in increased catecholamine synthesis. 
According to distribution pattern Nordlundit has classified into three subtypes localized, generalized and universal.  Further generalized one can be categorized into acrofacial, vulgaris and mixed. Similarly localized is of three types namely focal, segmental, and generalized. , Kent and Al'Abadie found a high level of agony in people with vitiligo compared to the general population.  Immediate gratitude of a person difference from the normal is through their look. Not only can look indicate a primary difference but it can be seen as a resource of deviance in itself. As such vitiligo is hardly a disease of medical significance, but there is more of a social stigma attached to it because of cosmetic reasons. It, however, brings about great psychological apprehension to the patient who is more humiliated than the victim of any pain or discomfort.  Complication arising due to vitiligo is mostly cosmetic and lesions involving lips and oral mucosa are more resistant to medical therapies, as no melanocyte reservoir exists in these areas because of an absence of hair follicles. In early vitiligo, topical tacrolimus is seen to be effective to some extent. Topical pimecrolimus also found to be effective in some cases of mucosal depigmentation. 
Differential diagnosis for vitiligo includes nevus depigmentosus, lichen sclerosus, and chemical leukoderma. Nevus depigmentosa is most commonly encountered condition among these however it can be easily differentiated by the fact that this condition is congenital while vitiligo is acquired. Although both vitiligo and chemical leukoderma are acquired conditions but later is mostly associated with repeated exposure to certain chemical mostly containing phenolic group. To differentiate lichen sclerosus from vitiligo microscopic examinations is required. Lichen sclerosus is characterized by reduced thickness of epithelium along with hydropic degeneration of basal cells also active melanocytes can be identified in it.
Treatment for gingival vitiligo also includes gingival veneer that covers the natural gingiva and mimics coral pink color of normal gingiva. Main disadvantage of this is discomfort caused because of bulk of veneer. Another method that is used now a day is gingival tattooing. It is considered to be most reliable method of the present scenario. Before starting with the treatment, proper color matching of test sites with natural gingiva should be done. This should be given utmost importance as results are based on this step discrepancies can again lead to compromised esthetics. Extent of which tattooing should be performed is based on patients smile line. Several appointments are required to get natural like appearance. Submuosal injection of tattoo pigment has to be done with stainless steel hand instrument that has 7-10 sharp points. Tattoo pigment is same as that used for skin tattooing. That is soluble metal salt ink in water. Preoperative Nonsteroidal anti-inflammatory drugs and postoperative chlorhexidine mouthwash should be advised. Entire procedure takes about 5 weeks. ,
However, in this case, the patient was not aware about the lesion. Since it was totally asymptomatic patient did not want to undergo for any treatment. Therefore, counselling of patient regarding the disease was done and he is kept on regular follow-up.
| Conclusion|| |
Gingival vitiligo though a very rare condition reported till date is considered as a social stigma and newer techniques for the management of this condition should be required for psychological enhancement and improvement of patient's quality of life.
| References|| |
Ortonne JP, Bose SK. Vitiligo: Where do we stand? Pigment Cell Res 1993;6:61-72.
Ashok N, Karunakaran A, Singh P, Rodrigues J, Ashok N, Tarakji B, et al
. Gingival vitiligo: Report of a case and review of the literature. Case Rep Dent 2014;2014:874025.
Forschner T, Buchholtz S, Stockfleth E. Current state of vitiligo therapy - evidence-based analysis of the literature. J Dtsch Dermatol Ges 2007;5:467-75.
Guntakalla VR, Gooty JR, Palakuru SK, Mahipal N, Sailaja T. Depigmentation to Regimentation of Gingiva. Indian J Dent Adv 2013;5:1386-91.
Ezzedine K, Lim HW, Suzuki T, Katayama I, Hamzavi I, Lan CC, et al
. Revised classification/nomenclature of vitiligo and related issues: The Vitiligo Global Issues Consensus Conference. Pigment Cell Melanoma Res 2012;25:E1-13.
Nordlund JJ, Lerner AB. Vitiligo. It is important. Arch Dermatol 1982;118:5-8.
Hann SK, Park YK, Chun WH. Clinical features of vitiligo. Clin Dermatol 1997;15:891-7.
Hann SK, Lee HJ. Segmental vitiligo: Clinical findings in 208 patients. J Am Acad Dermatol 1996;35:671-4.
Kent G, Al'Abadie M. Psychologic effects of vitiligo: A critical incident analysis. J Am Acad Dermatol 1996;35:895-8.
Telang GH, Ditre CM. Blue gingiva, an unusual oral pigmentation resulting from gingival tattoo. J Am Acad Dermatol 1994;30:125-6.
Al-Shawaf M, Ruprecht A, Gerard P, Al-Abed A. Gingival tattoo, an unusual gingival pigmentation. Report of 4 cases. J Oral Med 1986;41:130-3.
Mani NJ. Gingival tattoo. A hitherto undescribed mucosal pigmentation. Quintessence Int 1985;16:157-9.
[Figure 1], [Figure 2], [Figure 3]