Discussion
depigmentation, inflammation, pain
DEPIGMENTATION, INFLAMMATION, RECURRENCE, HYPERPIGMENTATION
The role of pink (gingival) esthetics in enhancing the overall appearance, self-confidence, and personality of an individual cannot be overstated. Recent advances in esthetic dentistry aim to harmonize the functional and esthetic aspects of a smile, while taking into consideration patients’ unique values and needs. Therefore, there is a need to investigate cost-effective yet efficient techniques to ensure the accessibility of these esthetic treatments for all those who desire them.A variety of treatment modalities have been proposed and presented in the literature for the management of gingival hyperpigmentation, with lasers being the prevailing choice in contemporary practice. In spite of the overall advantages of laser depigmentation, it remains a technique sensitive procedure that requires expensive equipment and proper training before usage. Conversely, while vitamin C has gained widespread recognition as a depigmenting agent in dermatology, its application for gingival depigmentation has been sparsely documented [Hence, this study was conducted to evaluate and compare the clinical performance, pain perception and patient satisfaction of vitamin C mesotherapy and diode laser ablation therapy in managing physiologic gingival hyperpigmentation. To the best of our knowledge, this is the first randomized clinical trial to compare between these two treatment modalities.Our findings indicate that both treatment modalities were successful in effectively managing gingival hyperpigmentation, highlighting the efficacy of both approaches in managing this common esthetic concern.In the diode laser group, there was a significant reduction in pigmentation indices following treatment. These results were consistent with several other published studies [With laser depigmentation, the absorption of the laser light by melanocytes is influenced by the wavelength of the laser used, and its depth of penetration. Melanin, being the target chromophore, has an absorption spectrum ranging between 351 and 1064 nm. Hence, 980 nm diode laser was chosen as it is highly absorbed by soft tissue with a particular affinity for chromophores, like melanin and oxyhemoglobin. Additionally, it offers great tissue penetration, reaching depths of up to 10 mm [In the vitamin C mesotherapy group, the pigmentation indices (DOPI and GPI) showed a decrease in indices’ scores with a significant statistical difference between baseline scores and follow-up visits’ scores, confirming the effectiveness of vitamin C as a depigmenting agent. These findings aligned with other clinical studies that revealed significant improvement in gingival color with the vitamin C mesotherapy technique [There are various mechanisms by which vitamin C reduces the gingival hyperpigmentation. Firstly, it suppresses the tyrosinase activity, the rate-limiting enzyme in melanin biosynthesis, through cytoplasmic acidification. Given that vitamin C is an acidic compound, it causes intracellular acidification of melanocytes, which reduces melanin production since the activity of tyrosinase is generally minimal in an acidic environment [As a result of the aforementioned mechanisms, vitamin C has a significant impact on hyperpigmentation, although its effects may take longer to manifest compared to the rapid outcomes achieved through laser therapy.Furthermore, previous studies have demonstrated the synergistic effects of vitamin C injection on the enhancement of the overall gingival health and reduction of inflammation [Although the two treatment modalities have proven to be statistically significant in reducing the intensity and areas of gingival pigmentation, the intergroup comparison showed statistically significant difference in favor of the Laser group.This could be attributed to the fact that the mechanism of gingival depigmentation by diode laser and vitamin C is entirely distinct. As diode laser therapy involves the complete removal of the surface epithelium, along with the melanocytes contained within it [Hence, we may conclude that the choice of the gingival depigmentation technique should be driven by multiple factors; including the patient’s financial status, the patient’s compliance to treatment, the operator’s skills, the overall health of the gingival tissue, the intensity of the gingival pigments and the gingival biotype.In terms of pain perception, the participants in the Laser group reported less levels of pain immediately after treatment than those in the Mesotherapy group. This could be attributed to several factors. The pain scores reported just after treatment in the Mesotherapy group were probably only due to the discomfort associated with the multiple injections required for that treatment method. In contrast, the reduction in pain reported by laser group could be explained by the protein coagulum that forms on the treated surface, acting as a biologic barrier that seals sensory nerves endings. Additionally, the photobiomodulation effects of laser therapy can play a role in reducing pain [In our study, a questionnaire was used to evaluate the patients’ satisfaction with the esthetic outcome achieved after 3 months, as well as their acceptability of the treatment method employed in both groups. Overall, the patients expressed high levels of satisfaction, indicating positive esthetic outcomes for both treatment modalities. Notably, there was no statistically significant difference observed between the two groups in terms of satisfaction and acceptability of the treatment method.While the present study provides valuable insights into the research topic, there are some limitations that should be taken into consideration. Longer follow up periods may be required to assess the recurrence rate following each depigmentation technique. Besides, the mesotherapy technique involves multiple injections, which can be uncomfortable for some patients. This can limit the use of this technique in certain patient populations, such as those with needle phobia. In addition, the requirement for multiple visits for vitamin C mesotherapy can pose a drawback as it increases the need for patient’s compliance.Another consideration involves the random treatment assignment of both maxillary and mandibular gingiva to either vitamin C mesotherapy or diode laser ablation, which could be seen as a limitation, as the maxillary gingiva has a relatively thick phenotype compared to that of the mandibular region. Therefore, it is advised that future studies take into consideration the gingival phenotype and consider its potential influence on the outcomes.