Abstract, Title and references

The title is very short and too the point, could be improved by referencing the oral cavity (if only to make it easier for search terms). In the abstract there is an interesting use of tense in the objective portion, starts off in past tense and begins a little clunky 'disconcerting' may not be the best adjective for the aesthetic concerns caused by amalgam tattoos. The aim isn't very clear, only mentions amalgam in the last sentence of the objective, it would be more appropriate to give context on amalgam. The conclusion in the abstract is clear and succinct. In the clinical significance portion the reiteration of 'patients smile' seems a little informal. 25 references show comprehensive research was undertaken in the writing of this paper. The referencing style seems consistent. Papers from 1983-2019 were used indicating a combination of both current and older sources of information

Introduction and Background

The opening sentence of the introduction does not clearly introduce the context of the paper. "Laypersons have considerable negative perception to color changes caused by pigmentation of the gingiva", it is informal and does not give a strong indication of the main focus area of the paper, amalgam tattoos. Pigmentations is not defined but their causation is well illustrated. The context given in the entirety of the introduction is quite limited with little definitions of key concepts. This limited exploration is quickly followed by a description of the methods which seems out of place. Apart from the opening sentence discussing the 'negative perception' pigmentation found on gingiva there is no justification as to why this issue is a suitable subject of research. A discussion about the psychological impacts of poor aesthetics or the social implications i.e. employment prospects due to undesirable pigmentation on the face, could greatly improved the justification of this research. The introduction alludes that two techniques to address a 'tattoo in the smile zone' will be used to improve the aesthetics of a patient. the research question itself is reasonably convoluted and could be clearer. A statement about improving aesthetics to maintain a patients well being could help direct a more structured conversation about the purpose of this research.

Methods

This article mentions subject selection in the introduction whereby it is stated that subjects were chosen due to their overall health being of a high standard as well as a radiographic history of amalgam fillings. There were only 3 participants in this study and the criteria was limited to what is mentioned above. Variables are not mentioned i.e. age, ability to heal, effects of natural pigmentation therefore they are not measured. The measurements appear to be the visual recognition of the tattoo minimising. As there is no control of variables nor a large sample size the study cannot be called valid or reliable. The methods are explained in a reasonably detailed manner through case photos accompanied by descriptions of the techniques used to eliminate the tattoos, therefore the study could be replicated to some extent.

Results

The results are clearly displayed in the form of high quality clinical photographs, it is therefore very clear to see the results of the treatment (no table or figures are relevant to this study). The text describing the results of the treatment is useful and not repetitive. It is clear that the treatment conducted to remove these amalgam tattoos was successful and therefore could be used by other practitioners in the future to restore the aesthetic zone of the oral cavity. The results are put into context by a comparison with previous misconceptions about removal of amalgam tattoos, this allows for the results to be appreciated as significant. They are definitely not over interpreted as the clear loss of the amalgam tattoo does not leave much for interpretation.

Conclusion and Discussion

The conclusion answered the presumed aim of the study (to remove amalgam tattoos in the most effective, least traumatic, fashion in order to restore aesthetics). Appropriate references are used and the results support the success of the treatment stated in the conclusion. Limitations are not mentioned in the discussion therefore they do not allow an opportunity for future research to be directed

Overall Review

This case article addresses the treatment of amalgam tattoos on 3 patients using keratinised gingival grafts and connective tissue grafts. The aim of this treatment is to remove pigmentation in the aesthetic zone of the oral cavity in order to improve patients appearance in the least traumatic way possible. This paper found that these techniques, which are reasonably conservative compared to traditional approaches, were very successful in removing the pigmentations left by the amalgam tattoos. The strength of this article comes from its clear display of procedures and results through high quality digital photography taken before, during and after treatment. This presentation of results allows for easy interpretation of the treatment as well as tools for replication. Major points in the article which needs clarification, refinement, reanalysis, rewrites and/or additional information and suggestions for what could be done to improve the article.

1. The introduction could provide more context on amalgam and the aim could be made clearer
2. A clearer methodology section of the paper (that describes the treatments in detail, as well as their recorded success among other clinicians)
3. A large sample size of patients in order to improve reliability of these methods
4. A discussion of weaknesses in the paper would allow for future studies to improve their study design

Minor points like figures/tables not being mentioned in the text, a missing reference, typos, and other inconsistencies.

1. Informal language
2. Inconsistent tense in the introduction
3. Further criteria for subject selection