Oral Pigmentation-2
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Transcript Oral Pigmentation-2
Melanocytes are pigment-producing cells that
are derived from neural crest cells
Melanin is formed from tyrosine by the action of
tyrosinase
Oral melanin pigmentation ranges from brown
to black to blue according to the amount of
melanin production and the depth of the
pigment.
Etiology
Congenital or acquired
Benign or malignant
Endogenous or exogenous
Causes of Oral Pigmentation
Congenital
Racial (Melanoplakia)
Naevi
Peutz-Jegher’s syndrome
Acquired
Endocrinopathies
Metabolic (Hemochromatosis)
Neoplastic
Metals
Food/drugs (oral contraceptives, antimalarials ,
minocycline tranquilizers)
AIDS
Benign causes of oral pigmentation
Physiologic pigmentation
Ephelides
Lentigo
Oral melanotic macule
Smoking melanosis
Intraoral nevi
Malignant causes of oral
pigmentation
Melanoma
Neuroectodermal tumor of infancy
Endogenous causes
Postinflammatoty
hyperpigmentation
Melanoacanthoma
Addison’s syndrome
Peutz- Jegher’s syndrome
Laugier-Hunziker syndrome
Exogenous
Drugs
Amalgam tattoos
Cultural or medical tattooing
Jailhouse tattoo
Heavy metals
Racial pigmentation
Results from increased amount of melanin
pigmentation
Usually in Blacks and Asians, but also
Mediterranean littoral
May be present in white descendents
Usually involves the gingivae (attached), but can
affect other oral sites
Variable colour and extent
Asymptomatic
Racial pigmentation
Differential diagnosis:
Addison’s disease
Albright’s Syndrome
Heavy metal pigmentation
Use of antimalarial drugs
Ephelides
Ephelides are sun-induced freckles that
are most commonly seen in very fairskinned individuals, especially those
with red or auburn hair.
They occur most frequently in
childhood, and tend to reduce in
number with age.
Lentigo
Solar lentigos, in contrast to ephelides are more common
in older individuals and persist indefinitely.
They are common on the face and may be seen in the
perioral region.
They range in size from 2 mm to 2 cm and are usually tan
to dark brown in colour.
Variation in colour or irregularity of outline should raise
the suspicion of lentigo maligna and is an indication
for histological evaluation.
Naevi
They are seen in mostly young
people between the ages of 20 and
39 years.
Sixty per cent are intradermal naevi
and approximately 25% are blue
naevi.
Naevi
Usually elevated
Palate is commonly affected site
Less than 1cm diameter
Not premalignant
Naevus of Ota
an acquired oculodermal
melanocytosis involving the skin of
the face, the eyes and mucous
membranes.
It is most common in Japan,
appearing usually in female
patients in early adult life.
Melanoacanthoma
Rare
Usually a feature of blacks
Aetiology unclear but probably secondary to
physical trauma
Areas of melanotic hyperpigmentation, typically
beneath a denture
They present as slightly elevated circumscribed
solitary asymptomatic pigmented plaques.
Melanoacanthomas have been reported to occur
on buccal, palatal and gingival mucosa.
Requires to be differentiated from Addison’s
disease
No premalignant potential
Endocrinopathies causing oral
pigmentation
Addison’s disease
Nelson’s syndrome
Ectopic ACTH production
Pregnancy
Addisonian pigmentation
May arise with any cause of adrenocortical
hypofunction (autoimmune, infection,
tumour)
Typically involves the buccal mucosa
May be the only clinical features of
adrenocortical hypofunction
The pigmentation is secondary to increased
ACTH production by the anterior pituitary
Addisonian pigmentation
Pigmentation is not specific to
Addison’s however if associated with
candidal infection, endocrine studies
should be performed
Brown or black color is seen in more
than 75% of Addison’s patients
Nelson’s syndrome
Rare
Excess ACTH production and pituitary
expansion secondary to bilateral
adrenalectomy for Cushing’s disease.
10% develop oral pigmentation
Oral pigmentation like Addison’s
disease
Ectopic ACTH production
Rare
Excess ACTH production by bronchial
adenocarcinoma
Oral hypermelanotic pigmentation
similar to Addison’s disease, but
possible additional involvement of the
soft palatal mucosa
Chloasma
Feature of late pregnancy
Manifests as melanotic
hyperpigmentation of the midface
Involvement of the oral mucosa is
extremely rare
Albright’s (McCune-Albright)
syndrome
Rare
Polyostotic fibrous dysplasia, sexual
precosity, cutaneous
hyperpigmentation, occasional other
endocrinopathies
Possible melanotic hyperpigmentation
of the oral mucosa (in addition to
unilateral or bilateral fibrous dysplasia)
Haemochromatosis
Autosomal recessive
Mechanism of iron overload not clear
Iron deposition in hepatocytes
More commom in males (female
menstruation will lessen the iron load)
Usually does not present clinically until
the 5th decade
Haemochromatosis
Investigations:
Elevated serum iron, reduced
TIBC, elevated ferritin
Iron in hepatocytes of biopsy
Thalassemia
Patients may have a dusky-brown
complexion - reflects iron
accumulation post-transfusion
Rarely there may be melanotic
pigmentation of the oral mucosa
and gingivae
Melanoacanthoma
Pigmentary incontinence
Uncommon
Usually arises in late age in association with
oral lichen planus
Patients are often tobacco smokers
Areas of melanotic pigmentation in site of
present or past lichen planus
Asymptomatic
Exclude Addison’s disease
Smoker’s Melanosis
Drug-induced oral mucosal
pigmentation
olours can be blue, brown, black,
grey, green
C
Drug-induced oral mucosal
pigmentation
Blue
Amiodarone
Antimalarials
Bismuth (overdose)
Mepacrine
Minocycline
Quinidine
Silver
Sulphasalazine
Drug-induced oral mucosal
pigmentation
Brown
Betal nut
Busulphan
Clofazimine
Oral contraceptives
Cyclophosphamide
Doxorubicin
Doxycycline
Fluorouracil
HRT
Heroin
HRT
Ketoconazole
Menthol
Minocycline
Pholphthalein
Propanolol
Zidovudine
Drug-induced oral mucosal
pigmentation
Black
Amiodaquine
Betal nut
Methyldopa
Drug-induced oral mucosal
pigmentation
Green
Copper
Grey
Amiodiaquine
Chloroquine
Fluoxetine
Hydroxycholoquine
Lead
Silver
Tin/zinc
Local causes of oral pigmentation
Ecchymoses
Ephelis
Melanoma and other malignancies
Melanoacanthoma
Naevus
Melanotic macule
Tattoos (amalgam, ink, graphite etc)
Local causes of oral pigmentation melanotic macules
Brown or black
Usually affect lips or gingivae
Arise at any age
Not premalignant
Oral Melanotic Macule
- tattoos
Caused by intentional or accidental implantation of
exogenous pigments into the mucosa
Amalgam tattoo or focal argyrosis is the most common
and appears as blue-black, non-elevated discoloration
that is usually irregular in shape and variable in size.
Deterioration of the silver compounds of the amalgam
impart the characteristic color of the lesion
Can affect any where but the favorable site is the gingiva.
The clinical diagnosis can be confirmed by radiography
otherwise failure of radiographic evidence necessitates
biopsy to rule out more serious lesions
tattoos
Other tattoos include graphite
pencil wounds and India ink
tattoos
Can reflect ritual (eg gingivae, lips)
May reflect lifestyle
Harmless
Amalgam Tattoo
Local causes of oral pigmentation bacillary angiomatosis
Rare
Usually a feature of HIV disease
Caused by Bartonella quintana or
Bartonella henselae
Gives rise to pigmented nodules
Can affect the skin, bone and liver
Responds to erythromycin
Local causes of oral pigmentation malignant melanoma
Oral disease is rare
Male:female ratio=2:1
Mostly in persons>50 years of age
Often affects the palate, mainly maxillary alveolar ridge,
anterior gingiva and labial mucosa, but can involve other
oral sites
Oral lesions may be primary or secondary tumours
Localised brown or black macule, papule, or nodule,
often with ulceration and destruction. Rarely lesions
may spread superficially
malignant melanoma
Early recognizable signs: asymmetric lesion,
border irregularity, color variation, and diameter
enlarging
Late signs: bleeding and ulceration, firmness on
palpation and rock-hard regional lymph nodes
Early diagnosis when tumors are less than 1.5 mm
in diameter and complete resection are critical to
long term survival.
Poor outcome likely
Malignant Melanoma
Ephelis (Freckle)
Light to dark-brown macule on the lip due
to exposure to light
Remains unchanged in size but may darken
Has predilection to light-skinned or redheaded persons
Investigation of oral pigmentation
History of present complaint
Medical history - hypoadrenocorticism, pulmonary
disease, drug history etc
Social history - tobacco or betel nut habit? ethnicity?
Extra-oral examination - evidence of cutaneous disease etc
Intra-oral examination - localised or generalised ?
Blood pressure
Serum electrolytes
24 hour urinary cortisol
Synacthen test
Biopsy
Discoloration of teeth
Extrinisic
Intrinsic
Smoking
Tetracycline
Beverages
Fluorosis
Drugs(iron,
Amelogenesis imperfecta
chlorehexidine,
minocycline)
Poor oral hygiene
Betel chewing
Kernicterus
Porphyria