Microneedling with Topical Vitamin C versus Scalpel Technique for the Esthetic Management of Physiologic Gingival Melanin Hyperpigmentation: A Randomized Controlled Clinical Trial

Gingival hyperpigmentation is a darker gingival color than what is normally expected. The hyperpigmentation caused sure to an "increased  production and release of the melanin by melanocytes in the basal and supra-basal layer is called "Gingival Melanosis". Physiological gingival melanosis/hyperpigmentation is not a pathological condition, but "black gums" represents an aesthetic concern for  many patients. Gingival depigmentation is a periodontal plastic procedure to reduce or remove hyperpigmentation from the gingivaConventional methodscommonly used, involvemechanical de-epithelization of pigmented gingivaand some underlying connective tissue with a scalpel, LASERS, electrocautery, bur, to obtain a regenerated epithelium free of melanin. Surgical stripping with scalpel, is the most time-tested, inexpensive technique and is considered gold standard for gingival depigmentation. However, is associated with disadvantageslike fear, post-operative pain, bleeding, discomfort and interference in normal activities of chewing, smiling etc. and higher rates of regimentation. Moreover, it is challenging to perform any of the surgical methods in cases of thin gingival biotype as it can sometimes lead to gingival recession and/or bone exposure. Therefore, there is a need to explore other minimally invasive non-surgical, simple, inexpensive therapeutic options as an alternative for the esthetic management of physiologic gingival hyperpigmentation.

Amongst the non-surgical approaches, vitamin C**(ascorbic acid) has recently been explored for gingival hyperpigmentation**. Vitamin C interferes with the steps of melanogenesis and causes depigmentation of tissues. Vitamin C offers additional advantages of having anti-inflammatory, antioxidant properties and promotion of collagen synthesis, making it a suitable therapeutic agent for both for skin and gingival health. Topical form though easier and painless to apply, has a poor availability due to salivary washout effect in oral cavity, and thus a weak depigmentation action. Injectable vitamin C (Intraepidermal oral mesotherapy),involves theintroduction of vitamin C into superficial layers of the oral tissue extending between basement membrane into superficial connective tissue using fine needles. Vitamin C mesotherapy has shown good patient outcomes due to psychological comfort of using non-surgical procedure, being cheap and minimally invasive, involving shorter appointments, and no interference with the normal oral functions.However, the drawback of injectable vitamin C is that penetration depth cannot be controlled. Although vitamin C is safe, it is a weak acidic product which can result in increased itching or tissue necrosis if given in higher dose or with a deeper penetration. Another consideration is product leak out from areas of canine eminence, mucogingival junction, and areas of very thin tissue biotype, thus tactile sensation is quite important. Hence, further exploration in this area is warranted to improve the delivery of vitamin C in gingiva to achieve better clinical and patient-reported outcomes.

In this context, use of microneeedling technique for gingival pigmentation can be explored, similar to its use in Dermatology. Microneedling as a standalone treatment or in combination with local therapeutics like vitamin C has gained popularity in recent years for managing skin hyperpigmentation’s like Melasma. Microneedling is a technique of repeated punctures by micron‐sized needles(height ranging from 0.025 to 2mm) that breach the outermost layer of the epithelium (stratum corneum) and creates tiny pores known as micro-conduits. In Dentistry, the use of microneedling is very recentwith scarce literature**.** A recent study has used microneedling with dermapen as a minimally invasive standalone treatment for gingival depigmentation with encouraging results. Exploring microneedling in combination with topical vitamin C can be advantageous as it can offer synergistic effects of depigmentation and collagen induction action of microneedling process together with improved delivery of vitamin C, a potent depigmentation and collagen promotion agent; through microchannels created. The dual benefit of depigmentation together with improvement of gingival thickness, could be advantageous in cases of thin gingival biotype, where performing surgical depigmentation technique is  challenging.

Currently, there is a paucity of studies comparing surgical and non-surgical gingival depigmentation techniques, with no definite guidelines. The present randomized trial aims to compare the clinical and patient-reported outcomes of  gingival depigmentation using non-surgical technique of microneedling (with Dermapen) with topically applied vitamin C versus conventional surgical scalpel technique.