Comparative Effectiveness of Gingival Depigmentation Techniques: A Systematic Review

Abstract

Gingival hyperpigmentation caused by melanin overactivity is a common aesthetic concern, and several depigmentation techniques—including scalpel surgery, electrosurgery, bur abrasion, grafts, lasers and adjunctive therapies—are available. However, their comparative effectiveness and long-term outcomes remain unclear. A comprehensive search of PubMed/MEDLINE, Central Register of Controlled Trials, Scopus, Web of Science, grey literature and clinical trial registries identified randomised controlled trials (RCTs) assessing depigmentation in physiologic pigmentation. Primary outcomes were aesthetic improvement and recurrence; secondary outcomes included healing, post-operative pain, patient satisfaction and adverse events. Nineteen RCTs with 10–60 participants and 3–24-month follow-up were included. Laser-based approaches generally outperformed scalpel and electrosurgery in terms of post-operative discomfort, haemostasis and epithelialisation. Diode lasers provided superior haemostasis and stable pigment control, whereas erbium, chromium, yttrium, scandium, gallium garnet (Er, Cr:YSGG) and erbium-doped yttrium aluminium garnet (Er:YAG) lasers offered greater comfort and faster healing but exhibited variable recurrence rates. Acellular dermal matrix (ADM) grafting resulted in markedly lower recurrence than abrasion. Adjunctive methods—including vitamin C mesotherapy, microneedling with ascorbic acid and injectable platelet-rich fibrin (i-PRF)—produced enhanced pigment reduction, improved healing and high satisfaction. Photobiomodulation with hyaluronic acid also yielded encouraging short-term outcomes. Small trials comparing diode with cryosurgery or CO₂ lasers showed similar clearance, with diode favouring bleeding control and comfort. Evidence certainty ranged from low to moderate due to small samples, heterogeneous laser parameters and limited long-term data. Diode and erbium, chromium, yttrium, scandium, gallium garnet (Er, Cr:YSGG)/erbium-doped yttrium aluminium garnet (Er:YAG) lasers appear to be effective depigmentation modalities with distinct clinical advantages. ADM grafts, vitamin C mesotherapy and i-PRF appear promising. Larger standardised multicenter trials with longer follow-up durations are needed.