ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10015-2174 |
Evaluation of Characteristics of Gingival stippling in Adult Population. A Clinical Study
1–4Department of Periodontics and Implant Dentistry, CSI College of Dental Sciences and Research, Madurai, Tamil Nadu, India
Corresponding Author: Nivethitha Maruthamuthu, Department of Periodontics and Implant Dentistry, CSI College of Dental Sciences and Research, Madurai, Tamil Nadu, India, Phone: +91 9080063924, e-mail: dpmnivi@gmail.com
Received on: 09 February 2022; Accepted on: 04 February 2023; Published on: 25 March 2023
ABSTRACT
Aim: The present study aims to describe stippling patterns in terms of number, size and location and evaluate their gender-specific differences.
Materials and methods: Around 250 subjects aged between 10 and 35 years were recruited for the study. The gingival examination included the evaluation of stippling patterns in different areas of attached gingiva followed by impression making that was done with custom-made trays and variation in impression making was standardized with stone casts and photographs made with digital single-lens reflex camera (DSLR) camera. The characteristics of stippling were analyzed and subjected to statistical analysis.
Results: According to size, the fine form was more in occurrence to bulbous and there was no significant difference between sexes. Based on the number, sparse was more prevalent when compared to numerous and moderate and between the sexes, there was a significant difference in the number of stippling in the maxillary labial (p < 0.03) and palatal (p < 0.01) and mandibular lingual region (p < 0.01). Based on the quantity, the light form was more occurrence than heavy and between sexes, significant differences were found for the quantity of stippling only in the maxillary palatal region (p < 0.05). In both arches, stippling was most prevalent in the interpapillary (84.2%) compared to interradicular (74.65%), and radicular (23.3%) regions.
Conclusion: The characteristics of gingival stippling based on the size, number and quantity showed significant variation between sexes and this variation might be attributed to factors such as keratinization and the relative position of teeth. So, accessing the stippling with a larger study population would consider stippling as a valuable diagnostic aid.
Clinical significance: Gingival stippling seems to be a unique characteristic of every individual. It varies in terms of number, size, and quantity. Rugae and fingerprints are utilized in forensic sciences for the identification of age, sex, and individuals, along with dental and osseous characteristics. If the stippling pattern and its reliability are further studied, then in the future, it might be used as a major diagnostic aid and as a valuable identification marker in forensic dentistry.
How to cite this article: Balaji VR, Dhanasekaran M, Govindasamy R, et al. Evaluation of Characteristics of Gingival stippling in Adult Population. A Clinical Study. World J Dent 2023;14(1):41-46.
Source of support: Nil
Conflict of interest: None
Keywords: Gingiva, Interpapillary, Interradicular, Keratinization, Stippling.
INTRODUCTION
Stippling is an adaptive specialization/response of the gingiva, which makes it look like an orange peel. Gingival stippling is a specialized feature of attached gingiva and its presence is considered a sign of gingival health.1 In the case of gingival inflammation, loss of stippling occurs.2 The stippling is present as elevations and depressions, which occur due to connective tissue projections within the tissue.3-5 There is a close association between the extent and degree of keratinization.6 The stippling varies with more prominence on the facial surface when compared to the lingual side.7 There is a lack of evidence regarding the use of stippling as an aid for the diagnosis and detection of disease and hence further studies are needed.8,9
Although there are a number of studies in medical literature, Ziskin and King were the first to study the clinical appearance of stippling.3,7 King described the normal gingival surface as “matte” in texture.3 Later, Orban demonstrated that the minute depressions, called stippling-were limited only to the epithelial layer and concluded that these depressions were caused by reticular elevations of the underlying connective tissue.10
There are various methods to assess the characteristics of stippling. In 1962, Greene studied the location of stippling, the individuality of stippling, differences in stippling between the sexes, differences in stippling among age-groups, and the microscopic appearance of stippling using high-resolution photographs and biopsies.11 Rosenberg, in 1967, utilized photographs and impressions to study the pattern of gingival stippling.12
In 1955, Fehr, Hans R, and Muhleman studied the surface characteristics of the free and attached gingiva with the replica method originally given by Scott and Wyckoff and Vendrine et al., and observed the alternate depressions and elevations on the gingival surface.13
Previous studies done to date have not defined the characteristics of stippling in different areas of attached gingiva based on the size, number and quantity, and variation between the sexes.
So, the aim of the present study was to evaluate and describe characteristics of stippling in different areas of attached gingiva based on number, size and quantity, and variation between the sexes.
MATERIALS AND METHODS
A total of 250 subjects aged between 18 and 35 years were recruited for the study. Individuals were selected through convenience sampling.
Inclusion Criteria
-
Apparently healthy gingiva.
-
Systemically healthy individuals.
Exclusion Criteria
-
Previous history of gingival and periodontal diseases.
The study was conducted in the Department of Periodontics at CSI College of Dental Sciences and Research, Madurai, from May 2019 to June 2020. A total of 250 subjects aged between 18 and 35 years were recruited for the study. Individuals were selected through convenience sampling. Participants who were systematically healthy with apparently healthy gingiva were recruited for the study. Participants with a previous history of gingival and periodontal diseases were excluded. The gingival examination included the evaluation of characteristics of stippling based on number, size, and quantity in different areas of the attached gingiva. Initially, the area of observation was wiped with a gauze piece and an examination was done under sufficient light. The areas include the interpapillary, interradicular, and radicular areas in both the maxillary and mandibular arches, according to classification by Greene et al. (Fig. 1). The examinations were done clinically by a single examiner. This was followed by impressions (Figs 2 and 3) that were done with custom-made trays and variation in impression-making was standardized with stone casts and high-precision images made with DSLR camera.12 Based on the above procedures, the stippling patterns were entered in the case pro forma. The characteristics of stippling were analyzed using categories given by Greene in 1962. Then the data obtained were subjected to appropriate statistical analysis.
Fig. 1: The classification of the areas of the stippling as said by Greene. Cr, radicular; Ip, Interpapillary; Ir, interradicular
Fig. 2: Cast showing the pattern of stippling clearly
Fig. 3: Elastomeric impressions obtained to cross-check the pattern of stippling
Statistical Analysis
The statistical analysis was performed using Statistical Package for the Social Sciences 22. The percentage distribution of the study population was evaluated according to age and gender. The distribution of stippling and the percentage were recorded for the maxillary and mandibular anterior gingivae on the palatal and labial aspects. The quantity, size, and number of stippling in different areas of the attached gingiva were evaluated. The difference in stippling characteristics according to quantity, size, and number between sexes was calculated using the chi-squared test.
RESULTS AND OBSERVATION
The majority of the population studied was in the age-group of 23 years (40%) and were predominantly females (Table 1). The distribution of stippling was more prevalent in the interpapillary region in the maxillary and mandibular anterior gingivae compared to the interradicular and radicular regions, with local distribution in the radicular region on the labial aspect (Table 2).
Variables | Number/frequency | percentage (%) | Total (n) |
---|---|---|---|
Age (years) 19 21 22 23 24 25 35 |
13 25 12 100 63 25 12 |
5.2 10 4.8 40 25.2 10 4.8 |
250 |
Gender Male Female |
38 212 |
15.2 84.8 |
250 |
Variables | Regions of stippling distribution | ||
---|---|---|---|
Regions | Interradicular n (%) | Interpapillary n (%) | Radicular n (%) |
Maxilla | |||
13 | Presence -225 (90) Absence -25 (10) |
Presence-238 (95.2) Absence-12 (4.8) |
Presence-12 (4.8) Absence-238 (95.2) |
12 | Presence-238 (95.2) Absence-12 (4.8) |
Presence-225 (90) Absence-25 (10) |
Presence-225 (90) Absence-25 (10) |
11 | Presence-212 (84.8) Absence-37 (14.8) |
Presence-225 (90) Absence-25 (10) |
Presence-100 (40) Absence-150 (60) |
21 | Presence-238 (95.2) Absence-12 (4.8) |
Presence-250 (100) | Presence-100 (40) Absence-150 (60) |
22 | Presence -225 (90) Absence -25 (10) |
Presence-238 (95.2) Absence-12 (4.8) |
Presence-75 (30) Absence-175 (70) |
23 | Presence-213 (85.4) Absence-36 (14.6) |
Presence-225 (90) Absence-25 (10) |
Presence-25 (10) Absence-225 (90) |
Mandible | |||
33 | Presence-175 (70) Absence-75 (30) |
Presence-188 (75.2) Absence-62 (24.8) |
Absence-250 (100) |
32 | Presence-200 (60) Absence-50 (40) |
Presence-200 (60) Absence-50 (40) |
Presence-50 (40) Absence-200 (60) |
31 | Presence-138 (55.2) Absence-112 (44.8) |
Presence-137 (54.8) Absence-113 (45.2) |
Absence-250 (100) |
41 | Presence-150 (60) Absence-100 (40) |
Presence-150 (60) Absence-100 (40) |
Presence-25 (10) Absence-225 (90) |
42 | Presence-125 (50) Absence-125 (50) |
Presence-125 (50) Absence-125 (50) |
Presence-37 (14.8) Absence-213 (85.2) |
43 | Presence-200 (60) Absence-50 (40) |
Presence-200 (60) Absence-50 (40) |
Presence-25 (10) Absence-225 (90) |
Total (n) = 250 |
The distribution of stippling was more in the interradicular region on the palatal/lingual side of the maxillary and mandibular region compared to the interpapillary and radicular region (Table 3).
Variables | Regions of stippling distribution | |
---|---|---|
Regions | Interradicular n (%) | Radicular n (%) |
Maxilla | ||
13 | Presence-188 (75.2) Absence-62 (24.8) |
Presence-12 (4.8) Absence-238 (95.2) |
12 | Presence-225 (90) Absence-25 (10) |
Presence-25 (10) Absence-225 (90) |
11 | Presence-225 (90) Absence-25 (10) |
Presence-100 (40) Absence-150 (60) |
21 | Presence-212 (85.2) Absence-37 (14.8) |
Presence-100 (40) Absence-150 (60) |
22 | Presence-212 (85.2) Absence-37 (14.8) |
Presence-12 (4.8) Absence-238 (95.2) |
23 | Presence-238 (95.2) Absence-12 (4.8) |
Presence-62 (24.8) Absence-188 (75.2) |
Mandible | ||
33 | Presence-200 (60) Absence-50(40) |
Presence-63 (25.2) Absence-187 (74.8) |
32 | Presence-200 (60) Absence-50 (40) |
Presence-50 (40) Absence-200(60) |
31 | Presence-163 (65.2) Absence-87 (34.8) |
Presence-3 (25) Absence-17 (75) |
41 | Presence-200 (60) Absence-50 (40) |
Presence-50 (40) Absence-200 (60) |
42 | Presence-163 (65.2) Absence-87 (34.8) |
Presence-25 (10) Absence-225 (90) |
43 | Presence-188 (75.2) Absence-62 (24.8) |
Presence-25(10) Absence-225 (90) |
Total (n) = 250 |
The size of the stippling was categorized as fine and bulbous. The fine type was found to be 61.3% and bulbous was found to be 31.25%. The number of stippling was categorized as numerous, moderate, and sparse. The numerous was 2.6%, the moderate was 19.9%, and the sparse was 66.3%. The localization was categorized as interpapillary, interradicular, and radicular. The interpapillary was found to be 84.2%. The interradicular was found to be 74.65% and the radicular was found to be 23.3%. These regions were analyzed and named interpapillary, interradicular, and radicular by Greene et al. (Fig. 1) and hence followed in this study. He named the regions where the stippling is present as interpapillary, interradicular, and radicular. The area which had more stippling had more keratinization in the same area. Though there were mild similarities between the sexes, no two individuals had the same size and number in the same location.
In the four regions observed, the mandibular labial region was presented with heavy stippling more frequently. The maxillary palatal region was presented with light stippling more frequently. The bulbous size was more frequent in the maxillary palatal region than in other regions. The fine size was more frequent in the maxillary labial region than in other regions (Table 4) (Figs 4 and 5).
Variable | Criteria | Regions | |||
---|---|---|---|---|---|
Maxillary labial n (%) | Maxillary palatal n (%) | Mandibular labial n (%) | Mandibular labial n (%) | ||
Quantity | Heavy | 50 (20) | 25 (10) | 38 (15.2) | 175 (70) |
Light | 200 (80) | 225 (90) | 162 (64.8) | 75 (30) | |
Absence | – | – | 50 (20) | – | |
Size | Bulbous | 12 (4.8) | 238 (95.2) | 25 (10) | – |
Fine | 238 (95.2) | 12 (4.8) | 175 (70) | 188 (75.2) | |
Absence | – | – | 50 (20) | 62 (24.8) | |
Number | Numerous | 13 (5.2) | – | 13 (5.2) | – |
Moderate | 87 (34.8) | 50 (20) | 37 (14.8) | 25 (10) | |
Sparse | 150 (60) | 187 (74.8) | 163 (65.2) | 163 (65.2) | |
Absence | – | 13 (5.2) | 37 (14.8) | 62 (24.8) | |
Total (n) = 250 |
Fig. 4: The appearance of stippling in the maxillary anterior region on the labial side. They are fine and numerous
Fig. 5: The appearance of stippling on the lower labial side. They are fine and sparse
Table 4 depicts the quantity, size, and number of the stippling present on the labial and lingual side of both the maxillary and mandibular anterior regions. Regarding the quantity, mostly the stippling observed was light. The stippling was rather fine compared to the bulbous size. The occurrence of stippling was found to be frequently sparse compared to numerous and moderate (Table 4).
According to differences between the sexes, there was a significant difference in the number of stippling in the maxillary labial (p < 0.03) and palatal (p < 0.01) region and mandibular lingual region (p < 0.01). Based on the quantity between sexes, significant differences were found for the quantity of stippling only in the maxillary palatal region (p < 0.05). There were no statistically significant differences in the size of the stippling between the sexes (Table 5).
Variable | Regions (n) | Gender | X2 value | p-value | |
---|---|---|---|---|---|
Female | Male | ||||
Quantity | Maxillary labial | Heavy-25 Light-187 Absent-0 |
Heavy-25 Light-163 Absent-0 |
4.804 | 0.08 |
Maxillary palatal | Heavy-25 Light-187 Absent-0 |
Heavy-0 Light-38 Absent-0 |
7.582 | 0.05* | |
Mandibular labial | Heavy-13 Light-150 Absent-50 |
Heavy-25 Light-163 Absent-0 |
0.392 | 0.716 | |
Mandibular labial | Heavy-0 Light-138 Absent-75 |
Heavy-0 Light-38 Absent-0 |
1.513 | 0.521 | |
Size | Maxillary labial | Bulbous-13 Fine-200 Absence-0 |
Bulbous-0 Fine-38 Absence-0 |
0.186 | 1.0 |
Maxillary palatal | Bulbous-0 Fine-200 Absence-13 |
Bulbous-0 Fine-38 Absence-0 |
0.186 | 1.0 | |
Mandibular labial | Bulbous-2 Fine-138 Absence-50 |
Bulbous-0 Fine-38 Absence-0 |
1.513 | 0.46 | |
Mandibular labial | Bulbous-0 Fine-150 Absence-63 |
Bulbous-0 Fine-38 Absence-0 |
1.176 | 0.53 | |
Number | Maxillary labial | Numerous-0 Moderate-63 Sparse-150 Absence-0 |
Numerous-13 Moderate-25 Sparse-0 Absence-0 |
8.779 | 0.03* |
Maxillary palatal | Numerous-0 Moderate-13 Sparse-188 Absence-13 |
Numerous Moderate-38 Sparse-0 Absence-0 |
14.118 | <0.01* | |
Mandibular labial | Numerous -0 Moderate-25 Sparse-150 Absence-38 |
Numerous -13 Moderate-13 Sparse-13 Absence-0 |
7.582 | 0.1 | |
Mandibular labial | Numerous-0 Moderate-0 Sparse-150 Absence-63 |
Numerous-0 Moderate-25 Sparse-13 Absence-0 |
12.810 | <0.01* |
*p < 0.05
DISCUSSION
The stippling can be effectively used as diagnostic aid based on the determination of its characteristics on the labial aspect. In the present study, among the various gingival regions, stippling distribution was less in the radicular regions when compared to other regions, which would have been influenced by root prominences and alignment of teeth.
In the literature, various methods have been utilized for the evaluation of stippling. Greene studied the stippling through clinical photographic and histologic evaluation.11 Rosenberg additionally utilized the casts and impressions to study the stippling.12 Whereas a negative replica method was utilized by Vendrine and others to study the stippling.14,15 The present study utilized high-resolution photographs, impressions, and casts to study stippling.
In the present study, during the examination, the maxillary gingiva had more stippling than the mandibular region. The labial region had more stippling than the lingual or palatal region, which was in accordance with the previous study.11 The differences in the stippling distribution can be explained due to the difference in the width of the attached gingiva among these regions.
The quantity of stippling was found to be light frequent than the heavy stippling and the difference in this result would be due to the age difference and the sex difference that occurred in the study population of previous studies.11,12 The present study evaluated this significant difference which was predominately observed in females when compared to previous studies.11,12
The sparse number was found to be more in occurrence than the numerous number. This can also be explained by the age and sex difference in the present study than in any other previous studies.
When assessing the distribution of stippling based on the quantity, number, and size, the results of the present study showed a positive correlation between stippling and the width of attached gingiva and root prominences.
Based on the difference in age and sex, the number of stippling was found to be more sparse compared to the findings observed in the earlier studies. Between the sexes, males had predominantly heavy stippling in comparison to light stippling, which was more in the females.
The fine size was found to be equally distributed among males and females. There was not much documentation about the bulbous type of stippling in the present study compared to the previous studies and the etiology is still unknown.
So, examining the stippling in the palatal region can give valuable information in the identification of sexes. Yet, future detailed research on this issue is required to confirm the results.
No two persons had the same stippling distribution with the same quantity, number and size. The stippling distribution in humans was found to be influenced by the width of the attached gingiva, root prominences, age, and sex of individuals. So, examining the stippling in a more objective way will definitely help us to identify the age and sex of individuals in the future.
There are studies that evaluated the characteristics in various age-groups and also involved young males.12 However, to the best knowledge of the authors, this is the first study of its kind where the characteristics of stippling were studied in young females in detail and its prevalence in the Indian population. Also, based on our observations, it was noted that no two persons had the same number, size, location, and pattern of gingival stippling. These variations seen in our study may be due to age, the width of the gingiva, angulation, and the position of teeth. The variations in the characteristics of stippling need to be studied in the larger study group than in the present study. The sample size in the present study is small to reach definitive conclusions and use stippling as a valuable diagnostic element. Rugae patterns are largely utilized in sex differentiation and based on the results of the present study, if stippling is further investigated in future studies, it could also be reliably considered for utilization in sex differentiation.
The limitations of the study include the small sample size, which has to be increased to arrive at more reliable results. The histologic evaluation through the biopsies for correlation of stippling with keratinization could have been included.
The presence of gingival stippling indicates the presence of a well-developed mucosal layer and is a positive sign of gingival health. Further evaluation and detailed description of stippling will add beneficial value in case stippling is utilized along with rugae and other soft tissues for diagnostic purposes.
CONCLUSION
The characteristics of gingival stippling based on the size, number, and quantity showed significant variation between the sexes, and this variation might be attributed to factors such as keratinization and the relative position of the teeth. So, accessing the characteristics of stippling with a larger study population would consider stippling as a valuable diagnostic aid.
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