In dentistry, stippling refers to the texture of the gingiva; the gingival tissue that is bound to underlying alveolar bone may have a textured surface that appears because of the microscopic depressions and elevations where connective tissue meets the gingiva. Some people compare this stippled appearance to the surface of an orange peel. Stippling is only a characteristic of attached gingiva and is not present in alveolar mucosa that moves freely, like the mucosa that lines the insides of the cheeks or the floor of the mouth. At one time, stippling was believed to be an indicator of the health of the gingiva, though it is now believed that stippling is only a marker of health if the characteristic has disappeared; this means that gingival tissue that was once stippled and is now smooth may indicate disease, but gingival tissue that has always been smooth may be completely healthy. Stippling may disappear when the gingival tissues are inflamed, but it will reappear once the health of the gingival tissues is restored. It is usually more defined on facial surfaces, as opposed to lingual surfaces. Stippling also varies in configuration and size based on the age and gender of the person, and, even within the mouth of a single individual, many people show varying levels of stippling in different areas of the oral cavity. It is estimated that about 40% of adults and about 70% of children have some amount of stippling on their gingiva. Stippling generally appears at around age 4 or 5 and is absent before this; stippling also begins to disappear in elderly people. Usually, any semblance of stippling that was present in an individual’s mouth has disappeared by the age of 50.
Stippling occurs where the epithelial ridges and connective tissue connect behind the gingiva and appears to be related to the level of keratinization of the gingiva, meaning that gingival tissue with higher levels of keratin protein tends to appear more stippled. This keratinized gingival tissue is integral to supporting dental implants, maintaining the health of the oral cavity, preventing recession of the gums, and improving the overall appearance of the mouth and teeth. Keratin is a type of fibrous structural protein that guards epithelial cells, protecting them from damage, and includes scales, hair, feathers, horns, claws, hooves, and the epidermis, or outermost layer of skin, in vertebrate species. If the keratinized gingival tissue has receded or diminished due to loss of the teeth, soft-tissue grafting may be necessary to replace this keratinized tissue and provide adequate protection for the periodontium. A deficit of keratinized tissue can induce gingival inflammation, and chronic inflammation can lead to loss of bone and gum tissue. Additionally, inflammation can be painful and cause bleeding, which may increase the difficulty of maintaining adequate oral hygiene. Early diagnosis of gingivitis is therefore recommended, and noting a baseline of gingival stippling from patient to patient can aid with this earlier diagnosis; if once-stippled gingival tissue suddenly appears smooth, there is an excellent chance that this is an indication of early gingivitis or other pathology.