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38]

Case Report

Split mouth de-epithelization

techniques for gingival
depigmentation: A case series and
review of literature
Rahul Kathariya, A. R. Pradeep

Department of Abstract:
Periodontics, Gingival melanin pigmentation occurs in all races of mankind. Although clinical melanin pigmentation does neither
Government Dental present itself as a medical problem nor a disease entity, it is a major esthetic concern for many people, especially
College and Research Asians. Esthetic gingival depigmentation procedures can be performed in such patients with excellent results. This
Institute, Bangalore, case series presents a split mouth de-epithelization procedure using popular surgical techniques such as scalpel,
Karnataka, India bur abrasion or electrosurgery. These techniques were successfully used to treat gingival hyperpigmentation.
Although we found that electrosurgery increased the efficacy of our work, giving a cleaner and neater work field, it
required a lot of precision. In contrast, scalpel de-epithelization was easy and technique-friendly, giving excellent
results and patient satisfaction. However, the cases are being followed-up to study the factors affecting the rate
and length of time required for repigmentation and to study the repigmentation patterns. This case series also
reviews the advantages and disadvantages of various techniques available for depigmentation, and reiterates
that the scalpel technique still serves as a gold standard for depigmentation.
Key words:
Bur abrasion, depigmentation, electrosurgery, gingiva, melanin, physiological pigmentation, scalpel technique

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INTRODUCTION mm; hence, clinical pigmentation is evident.
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Therefore, the size and degree of melanization

T
DOI:
10.4103/0972-124X.84387
he color of the gingiva is determined by
several factors, namely number and size of
Quick Response Code:
the blood vessels, epithelial thickness, quantity
of keratinization and pigments within the
gingival epithelium. Melanin, carotene, reduced
hemoglobin and oxyhemoglobin are the main
pigments contributing to the normal color of
the oral mucosa.[1] Melanin, a brown pigment, is
the most common natural pigment contributing
to endogenous pigmentation of the gingiva.
Physiological pigmentation of the oral mucosa
(mostly gingiva), is clinically manifested as
multifocal or diffuse melanin pigmentation with
variable amounts in different ethnic groups
worldwide [2,3] and it occurs in all races. [2,4]
Melanin is deposited by melanocytes, mainly
located intertwined between the basal and the
Address for
suprabasal cell layers of epithelium,[5,6] often
correspondence:
Dr. Rahul Kathariya, observed to a greater degree at the incisors.[7]
Department of Periodontics, In Caucasians, most melanocytes have striated
Government Dental College granules that are incompletely melanized and
and Research Institute, vary in size from 0.1 to 0.3 mm. But, the amount
Bangalore - 560 002, is insufficient to cause pigmentation (less than
Karnataka, India. 10% demonstrate pigmentation). A high amount
E-mail: rkathariya@gmail.
com
of melanin granules is found in individuals of
African and East Asian ethinicity.[8] In them,
Submission: 13-11-2010 the granules are more completely melanized
Accepted: 17-04-2011 and form larger complexes of size about 1–3
of these granules is directly proportional
to the degree of pigmentation. [7] Also, there
appears to be a positive correlation between
gingival pigmentation and degree of dermal
pigmentation.[9] However, melanin pigmentation
of the gingiva is symmetric and does not alter the
normal gingival architecture.[2]
In dark-skinned and black individuals, an
increased melanin production has long been
known to be the result of genetically determined
hyperactivity of melanocytes. Melanocytes of
dark skinned and black individuals are uniformly
highly reactive, whereas in light skinned
individuals, melanocytes are highly variable in
reactivity.[10,11] In general, individuals with fair
complexion will not demonstrate overt tissue
pigmentation, even though comparable numbers
of melanocytes are present within their gingival
epithelium.[12]
Brown or dark pigmentation or discoloration
of the gingival tissue is however considered as
multifaceted etiology, including genetic factors[8]
(irrespective of age [2,4] and gender; [13] hence,
termed physiologic or racial pigmentations[2,14]),
tobacco use,[15,16] systemic disorders[17] (endocrine
disturbance, Albright’s syndrome, malignant

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Kathariya and Pradeep: Depigmentation by de-epithelization
melanoma, Peutz-Jeghers syndrome, hemachromatosis,
chronic pulmonary disease, Addison’s syndrome and
von Recklinghausen’s disease [neurofibromatosis]),[17,18]
antimalarial therapy,[19,20] tricyclic antidepressants and a variety
of local and systemic factors.[21]
Clinical melanin pigmentation is completely benign and does
not present a medical problem, although complaints of dark
gums may pose an esthetic concern, particularly if visible
during speech and smiling[22] Demand for cosmetic therapy
is made, especially by fair skinned people with moderate
or severe gingival pigmentation,[23] mostly in patients with
a high smile line (gummy smile). Gingival depigmentation
is a periodontal plastic surgical procedure whereby the
gingival hyperpigmentation is removed or reduced by various
techniques.
CASE PRESENTATIONS
Six patients [four male, two female [Figure 1]], all students,
aged 19–25 years visited the Department of Periodontics,
Government Dental College and Research Institute, Bangalore,
India, with the chief complaint of “dark gums” with loss of
confidence and embarrassment within their peer groups.
Two patients requested for any cosmetic therapy that would
eventually enhance the esthetics on smiling; the other four
were referred cases. The patients’ history revealed that
the blackish discoloration of gingiva was present since
birth, suggestive of physiologic melanin pigmentation.
Clinical examination revealed pronounced bilateral melanin
pigmentation associated with a healthy periodontium. Their
medical history was non-contributory. The patients were in
good general health and there were no contraindications for
the surgeries. All depigmentation areas were graded from 1
to 10 according to the “Weinman” scale of grading gingival
depigmentation. Considering the patient’s concern, a split
mouth surgical gingival de-epithelization procedure was
decided. A combination of scalpel de-epithelization, bur
abrasion or electrosurgery was planned [Figures 2-7].
Surgical procedure
About 2 ml of Lignocaine adrenaline local anesthesia was
administered as nerve block and/or infiltration. Two vertical
incisions were made on the side destined to undergo scalpel de-
epithelization (both distally and mesially) of the pigmentated
area using a #15 scalpel blade. A split thickness flap was raised
and excised, maintaining the normal architecture of the gingiva
[Figures 3, 4 and 6]. Bleeding was controlled using pressure
pack with sterile gauze. Sterile saline-soaked gauze was
placed on the recipient site to control bleeding. The exposed
depigmented surface was covered with Coe-pak periodontal
dressing for 1 week. The patient was prescribed Amoxicillin 500
mg, TD for 5 days and Aceclofenac–paracetamol combination
BD for 3 days and post-operative instructions were given. In
the next week, electrosurgery/surgical abrasion using diamond
burs was performed on the other side [Figures 2 and 8]. To
eliminate the demarcation between these two procedures, a
mesial incision was given with BP blade.
Electrosurgery
Needle electrode was used for incisions and ball electrodes
of different diameters were used to coagulate [Figures 7–9].
162 Journal of Indian Society of Periodontology - Vol 15, Issue 2, Apr-Jun 2011
Minimal bleeding with a clean field increased the efficacy of
the work [Figures 9 and 10]. Light brushing strokes were used
and the tip was kept moving all the time. Prolonged or repeated
application of electrode to the tissues was avoided as it induces
heat accumulation and causes undesired tissue destruction.
[24]
As it causes an undesired effect, enough care was taken to
avoid contact of current with the periosteum and vital teeth,
but at one point the tissue fenestrated [Figure 10].
RESULTS
Scalpel technique
No post-operative pain, hemorrhage, infection or scarring
occurred. Although mild inflammation at the canine–premolar
region [Figure 11] was observed in one case, healing was
uneventful. Patient’s acceptance of the procedure was
good and results were excellent as perceived by the patient
[Figure 12]. No repigmentation occurred for the initial 24 weeks
[Figure 13, patient 2, I quadrant], and the patient is being
monitored for longitudinal period for any repigmentation.
Surgical bur abrasion
The results were similar and comparable to the scalpel
technique. Patients’ acceptance of the procedure was good
and no repigmentation was reported till 12 weeks period
[Figure 13, patient 2, II quadrant], and the patient is being
monitored for a long term.
Electrosurgery
Mild post-operative burning and no post-operative
hemorrhage and infection occurred. Patient’s acceptance of
the procedure was not as good as contralateral surgery and
the results were not as promising. The patient kept saying
that the previous procedure was better [Figure 14]. Although
the patient is under observation for any scarring, a difference
in the color and texture between the two procedures was
apparent [Figure 14].
Although electrosurgery has advantages of minimal bleeding
and a cleaner work field, it requires more expertise and
caution. The results with the conventional split thickness
scalpel technique are excellent and better than electrosurgery.
This conclusion was also supported by the patients’ feedbacks.
DISCUSSION
To treat depigmentation and to enhance esthetics, numerous
techniques have been employed from time to time. This review
further compiles the advantages and disadvantages of each
technique.
Various techniques
1. De-epithelization
a. Scalpel technique[7,25,26]
b. Gingival abrasion technique using diamond bur[27,28]
c. Combination of the scalpel and bur[29]
2. Gingivectomy[30,31]
3. Gingivectomy with free gingival autografting[32,33]
4. Acellular dermal matrix allograft (ADMA)[34,35]
5. Electrosurgery[24]
6. Cryosurgery[36]
a. Using liquid nitrogren[36]
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Kathariya and Pradeep: Depigmentation by de-epithelization

Figure 1: Baseline (Left to right). Patient 1: 20 years male (Weinman score 10) Figure 2: Patient 2 – Bur abrasion (II quadrant) on the contralateral side after
Patient 2: 25-years-old male (Weinman score 7), 12 weeks post-treatment after scalpel de-epithelization (I quadrant, not shown)
scalpel de-epithelization Patient 3: 20 years female (Weinman score 10) Patient 4:
22 years female (Weinman score 10) Patient 5: 21 years male (Weinman score 10)
Patient 6: 19 years male (Weinman score 10)

Figure 3: Patient 3 – Scalpel de-epithelization procedure (I quadrant) Figure 4: Patient 4 – A single sitting scalpel de-epithelization with frenectomy
(upper arch)

Figure 5: Patient 5 – Diamond bur abrasion (I quadrant) Figure 6: Patient 6 – Scalpel de-epithelization (I quadrant)

Figure 7: Patient 6 – Needle electrode used to give incisoin, mesial incision was
given with a scalpel to avoid demarkation between the contralateral side Figure 8: Patient 6 – Outline of the incision using needle electrode

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Kathariya and Pradeep: Depigmentation by de-epithelization

Figure 9: Patient 6 – Ball electrodes of different diameters used for coagulation Figure 10: Patient 6 – Arrow showing fenestration between the canine and the
premolar region

Figure 11: Patient 6: 1 week post-treatment, mild inflammation in the canine Figure 12: Patient 1: 8 weeks post-operative following scalpel de-epithelization
premolar region (I quadrant)

Figure 14: Patient 6: 3week post-op after scalpel de-epithelization (I quadrant) and
12 days post-electrosurgery (II quadrant)
Figure 13: Post-treatment Patient 1 – 22 weeks post-operative (post-op) following
scalpel technique (I quadrant) and 2 weeks post-op following diamond bur abrasion (II
quadrant) Patient 2: 24 weeks post-op after scalpel de-epithelization (I quadrant) and Although any of the above techniques may be employed for
12 week post-op after bur abrasion (II quadrant) Patient 3: 22 weeks post-treatment depigmentation, selection of a technique should be based
after scalpel de-epithelization (I quadranat) Patient 4: 20 weeks post-operative after on clinical expertise, patient’s affordability and individual
scalpel de-epithelization and frenectomy (upper arch) Patient 5: 2 weeks post-
preferences. They should be performed cautiously, with care
treatment after bur abrasion (I quadrant) Patient 6: As Figure 13
to protect adjacent tissue, because inappropriate technique/
application may cause gingival recession, damage to the
b. Using a gas expansion system[37] periosteum and bone and may cause pain, discomfort and
7. Chemical agents delayed wound healing.[30]
a. 90% phenol and 95% alcohol[38]
b. Ascorbic acid De-epithelization
8. Laser[39] Scalpel[7,25,26]
a. Nd:YAG[40] The procedure essentially involves surgical removal of the
b. Semiconductor diode laser[41] gingival epithelium along with a layer of the underlying
c. CO2 laser[42] connective tissue under adequate local anesthesia and allowing
d. Argon laser[43] the denuded connective tissue to heal by secondary intention.

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Kathariya and Pradeep: Depigmentation by de-epithelization
The new epithelium that forms is devoid of pigmentation.[25]
Care must be taken to remove all remnants of the pigment layer
(to avoid chances of recurrences) and it should be removed in
thin sections to avoid exposing the underlying bone. Scalpel
de-epithelization is relatively simple and effective, and most
economical of all the other techniques available. It does not require
any sophisticated armamentarium, is easy to perform and, most
importantly, requires minimum time and effort.[44] Also, the
healing period for scalpel wound is faster than other techniques.
However, it might result in unpleasant hemorrhage during or
after surgery. Hence, it is necessary to cover the lamina propria
with periodontal dressing for 7–10 days.[26] It also has chances
of infection or recurrence. Results reported are excellent.[45] This
technique is highly recommended in the Indian subcontinent
considering equipment constraints and patient affordability.[26]
Gingival abrasion technique using diamond bur[27,28]
The process of healing in this method is similar to the
scalpel technique. It is also a comparatively simple, safe
and non-aggressive method that can be easily performed
and readily repeated, if necessary, to eradicate any residual
repigmentation. [46] Also, these techniques do not require any
sophisticated equipment and are hence economical. Pre- and post-
surgical care is similar to that of the scalpel technique. However,
extra care should be taken to control the speed and pressure of the
handpiece bur so as not to cause unwanted abrasion or pitting of
the tissue. Minimum pressure with feather light brushing strokes
with copious saline irrigation should be used without holding
the bur in one place to perceive excellent results.[47]
Gingivectomy[30,31]
Removing the gingival margin by gingivectomy or the entire
attached gingiva by the “push back” procedure may also
be used. However, these procedures are associated with
alveolar bone loss, prolonged healing by secondary intention
and excessive pain and discomfort caused by exposure and
denudation of the underlying bone.[18]
Gingival depigmentation has been attempted by displacing
the flap (push back technique) by Kon et al., who reported
that melanocytes may lose their ability, transiently, to produce
and transfer the pigment to the keratinocytes as observed after
gingivectomy.
Gingivectomy with free gingival graft[32,33]
Tamizi and Taheri [32] replaced pigmented gingiva with
unpigmented free gingival autografts in 10 patients. At least
two areas in each patient were grafted; one with a full thickness
flap and another with a partial thickness flap. They reported
no evidence of repigmentation for 4.5 years post-operatively in
areas that received a full thickness flap, and only one instance
of repigmentation was observed 1 year post-operatively in a
patient treated with a partial thickness flap. Although the results
were favorable, this technique required the use of additional
surgical sites with added discomfort, and healing was reported
to be slow and painful. The amount of tissue available in the
donor area was also limited. Moreover, the esthetic result was
not always satisfactory due to color differences between the
palatal tissues and the gingiva,[48] resulting in poor tissue color
matching at the recipient site.[49] Furthermore, the presence of
a demarcated line commonly observed around the graft in the
recipient site may itself pose an esthetic problem.
Journal of Indian Society of Periodontology - Vol 15, Issue 2, Apr-Jun 2011 165
Acellular dermal matrix allograft[34,35]
ADMA has been used to treat burn patients and patients with
soft tissue defects.[50] It is acellular and non-immunogenic and
healing occurs by repopulation and revascularization rather
than granulation to limit scarring.[51] Novaes et al. reported the
use of ADMA for elimination of the gingival pigmentation.[35]
These studies demonstrated the efficacy of the ADMA, with
the advantages of reduced surgical time (due to elimination
of the surgical procedure for donor tissue), decreased post-
operative complications, unlimited amount of graft material
and a predictable and satisfactory esthetic result. However, it
is expensive and requires clinical expertise.
Electrosurgery[24]
According to Oringer’s “Exploding cell theory,”[52] it is predicted
that electrical energy leads to the molecular disintegration of
melanin cells of the operated and surrounding sites. Thus,
electrosurgery has a strong influence in retarding migration
of melanin cells.[52] However, electrosurgery requires more
expertise than the techniques mentioned above. Prolonged
or repeated application of current to the tissues induces heat
accumulation and undesired tissue destruction.[24] Contact
of current with the periosteum and vital teeth should be
avoided. [42] Hence, it is to be used in light brushing strokes and
the tip has to be kept moving.
Cryosurgery[36] is a method of tissue destruction by rapid
freezing. The cytoplasm of the cells freezes, leading to
denaturation of proteins and cell death. It does not require
use of local anesthesia or periodontal dressing, is relatively
painless and has shown excellent results lasting for several
years. [23] The cryotherapy procedure requires a special
container for storage of liquid nitrogen (LN), and dispensing
is difficult as it is highly volatile (-190°C) and is difficult to
maintain for 20–30 s of freezing application. Moreover, the
depth of penetration is difficult to control and prolonged
freezing may cause excessive tissue destruction. Also, the
shelf-life of LN is not high for storage for long periods. It is
also important to handle the liquid carefully as accidental
contact can cause injury to the skin or other contact areas.
Also, no literature on dispensing, shelf-life or proper usage
directions is available.
The Dip-stick method utilizes a small cotton bud/swab
dipped in LN, which can be applied on the pigmented area
and maintained in contact for around 20–30 s as described
by Tal et al.[37] However, the removal of pigments cannot
be evaluated during the procedure as immediate clinical
changes are not appreciable and hence may lead to multiple
applications. It requires a separate sitting after about 5 days,
during which the residual pigmentation, if any, may be
removed. Thus, this procedure requires a minimum of two
sittings. Moreover, it is followed by considerable swelling
and accompanied by increased soft tissue destruction.[53] It is
said that all parts of the freeze–thaw cycle can cause tissue
injury and healing may be uneventful. As immediate clinical
changes cannot be noticed, it is difficult to analyze the site of
previous application and hence depth control is difficult. Also,
the optimal duration of freezing is not known and prolonged
freezing increases tissue destruction.[26] Tal et al.[37] did not
observe repigmentation until 20 months after cryosurgical
depigmentation.
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Kathariya and Pradeep: Depigmentation by de-epithelization
An alternative to the Dip-stick method is the use of gas-
expansion cryosurgical guns with special probes. But, this
requires extensive sophisticated equipment. It works on the
Joule-Thompson effect, i.e. the “change in temperature that
accompanies expansion of a gas without production of work
or transfer of heat. The cooling occurs because work must be
done to overcome the attraction between the gas molecules as
they move further apart.”
Chemical agents (chemoexfoliation)
It is a treatment method that destroys the epidermis and/or
dermis using a chemical peeling agent. A variety of chemical
peeling agents are available; phenols, salicylic acid, glycolic
acid, trichloracetic acid, etc. These agents have been classified
into four types: Very superficial, superficial, medium depth
and deep, based on their penetration.
90% phenol and 95% alcohol[22]
Phenol penetrates the subepithelial connective tissue and
causes necrosis or apoptosis of melanocytes. It result in
incapacity of melanocytes to normally synthesize melanin.[54]
Phenol does not seem to determine melanocyte destruction;
rather, it compromises its activity. Hirschfeld reported a series
with 20 cases that were treated for melanin pigmentation
with the phenol–alcohol method.[55] It requires the area to be
air-dried before application The phenol pellet is applied and
maintained for 1 min and the area needs to be rinsed with 99%
alcohol. Eighty-eight to 90% phenol rapidly coagulates the
epidermis thus decreasing its mucosal penetration. Although
application is easy and no anesthesia is required, care must
be taken not to contact other tissues as it causes undue effects.
Transient or definite hypopigmentation is a feature of phenol
cauterizing. It can be repeated subsequently until satisfactory
depigmentation is achieved.
Phenol de-epithelization may be accompanied with
inflammation of keratinocytes. [56] Burning sensation for
approximately 60 s, followed by a transient period and pain
returning after 10 min, with a lesser intensity that lasts from
minutes to hours, is known. Post-operative care should include
delicate cleaning of the gingiva with saline and prescribed
antibiotic regimen. Phenol may induce cardiac arrhythmia;
hence, hydration before, during and after the peel is required.
Cardiac monitoring is necessary, especially in patients with
cardiac, liver or kidney disease (partially detoxified in the liver
and excreted by the kidneys).
Lasers[39] are named according to the material used for the lasing
medium Nd/YAG (neodymium–yttrium-aluminum-garnet),
CO2, argon and ruby. Lasers combine the advantages of rapid
healing of the scalpel surgery and the minimal bleeding of
electrosurgery. A one-step laser treatment is usually sufficient
to eliminate the pigmented gingiva and does not require a
periodontal dressing. Easy handling, short treatment line,
hemostasis, sterilization effects and excellent coagulation (small
vessels and lymphatics) are its known advantages. The treated
area should be left exposed in the mouth. Few myofibroblasts
present in the base of the wound cause minimal contraction and
scarring, with little restriction in movement of the soft tissues.
However, laser surgery does have some disadvantages.
Delayed type of inflammatory reaction may occur with mild
166 Journal of Indian Society of Periodontology - Vol 15, Issue 2, Apr-Jun 2011
post-operative discomfort lasting up to 1–2 weeks. Epithelial
regeneration (re-epithelialize) is delayed (lack of wound
contraction) as compared to conventional surgery. Moreover,
expensive and sophisticated equipment makes the treatment
very expensive.[40] Another disadvantage is loss of tactile
feedback while using lasers. Nevertheless, in hyperplastic
conditions, for bloodless incision, partial thickness dissections
and for the removal of soft tissue grafts from the palate
leaving a dry wound (avoiding any post-operative bleeding
complications), use of lasers is recommended.
Growing esthetic concerns require patients to seek cosmetic
treatment for their unsightly pigmented gingiva. Several
treatment modalities have been suggested and presented in
the literature, ranging from a simple slicing method to free
gingival grafts or “push back” operation, in which the alveolar
bone may be, exposed leading to bone loss, secondary healing,
discomfort and pain. Although the scalpel technique results
in rapid healing with a satisfactory esthetic result, its efficacy
lasted for a variable duration of time, making this technique
mainly a short-term solution. The potential risk of injuring
the bone surface during rotary instrumentation may lead to
incomplete removal of the basal layer. Also, the presence of
epithelial rete-pegs that penetrate the connective tissue further
complicate the elimination of the basal layer by bur abrasion.
A free gingival graft usually requires an additional surgical
site and a careful concern for color matching. Furthermore, the
presence of a demarcated line around the graft at the recipient
site may itself elicit an esthetic problem. These disadvantages of
conventional techniques are avoided with newer technologies
like electrosurgery, cryosurgery and lasers. But, there exist some
complications with these techniques as well. An electrosurgical
procedure requires clinical expertise, occupies a large space
and is expensive. Cryosurgery requires a skillful management
because of the complicated technique and sophisticated
instruments involved. It also involves the various drawbacks of
using LN. Chemical agents such as 90% phenol and 95% alcohol
have been used in combination. However, these agents are quite
harmful to the oral soft tissues. Lasers lead to post-operative
discomforts, require a longer healing time, with high cost of
instruments and expensive treatment charges, making it less
popular compared with the other techniques.
Our cases described a split mouth comparison of three popular
techniques: Scalpel, bur abrasion and electrosurgery. Although
we found that electrosurgery increased the efficacy of our
work, giving a cleaner and a neater work field, it required
a lot of precision. The results obtained till 24 weeks post-
treatment suggested excellent results with the scalpel technique
compared with other techniques. In view of the advantages and
disadvantages of the various techniques available, scalpel de-
epithelization still serves to be the best treatment modality for
depigmentation. However, a long-term follow-up is required
to study repigmentation patterns and durability. Pigment
recurrence has been documented in the literature, following
the surgical procedure, within 24 days to as long as 8 years.
Spontaneous repigmentation has been shown to occur and
the mechanism suggested is that the melanocytes from the
normal skin proliferate and migrate into the depigmented
areas. Further research is required on repigmentation to study
the factors affecting the rate and length of time required for
recurrence of pigmentation. Research should also focus on
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Kathariya and Pradeep: Depigmentation by de-epithelization
finding a solution for preventing recurrence and, till then,
repeated depigmentation should be done to eliminate the
unsightly pigmented gingiva.
CONCLUSION
Gingival melanin pigmentations can occur as a consequence
of local, systemic, environmental or genetic factors. To ensure
treatment success, the potential causative or aggravating agent
of the pigmentation should be identified and eliminated, if
possible, before the surgical treatment. Various techniques
are available with some advantages and some drawbacks.
However, choice of the technique should be dependent
on individual preference, clinical expertise and patient
affordability. More data is required on comparative techniques
to ensure the long-term predictability and success.
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How to cite this article: Kathariya R, Pradeep AR. Split mouth
de-epithelization techniques for gingival depigmentation: A
case series and review of literature. J Indian Soc Periodontol
2011;15:161-8.
Source of Support: Nil, Conflict of Interest: None declared.

168 Journal of Indian Society of Periodontology - Vol 15, Issue 2, Apr-Jun 2011