Oral Pigmentation

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Oral Pigmentation
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• 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.

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Etiology

• Congenital or acquired
• Benign or malignant
• Endogenous or exogenous

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Causes of Oral Pigmentation

• Congenital
• Racial (Melanoplakia)
• Naevi
• Peutz-Jeghers syndrome
• Acquired
• Endocrinopathies
• Metabolic (Hemochromatosis)
• Neoplastic
• Metals
• Food/drugs (oral contraceptives, antimalarials ,
  minocycline tranquilizers)
• AIDS

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Benign causes of oral pigmentation

• Physiologic pigmentation
• Ephelides
• Lentigo
• Oral melanotic macule
• Smoking melanosis
• Intraoral nevi

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Malignant causes of oral pigmentation

• Melanoma
• Neuroectodermal tumor of infancy

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Endogenous causes

• Postinflammatoty hyperpigmentation
• Melanoacanthoma
• Addisons syndrome
• Peutz- Jeghers syndrome
• Laugier-Hunziker syndrome

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Exogenous

• Drugs
• Amalgam tattoos
• Cultural or medical tattooing
• Jailhouse tattoo
• Heavy metals

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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

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Racial pigmentation

• Differential diagnosis
• Addisons disease
• Albrights Syndrome
• Heavy metal pigmentation
• Use of antimalarial drugs

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Ephelides

• Ephelides are sun-induced freckles that are most
  commonly seen in very fair-skinned individuals,
  especially those with red or auburn hair.
• They occur most frequently in childhood, and tend
  to reduce in number with age.

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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.

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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.

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Naevi

• Usually elevated
• Palate is commonly affected site
• Less than 1cm diameter
• Not premalignant

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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.

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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.

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• Melanoacanthomas have been reported to occur on
  buccal, palatal and gingival mucosa.
• Requires to be differentiated from Addisons
  disease
• No premalignant potential

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Endocrinopathies causing oral pigmentation

• Addisons disease
• Nelsons syndrome
• Ectopic ACTH production
• Pregnancy

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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

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Addisonian pigmentation

• Pigmentation is not specific to Addisons however
  if associated with candidal infection, endocrine
  studies should be performed
• Brown or black color is seen in more than 75 of
  Addisons patients

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Nelsons syndrome

• Rare
• Excess ACTH production and pituitary expansion
  secondary to bilateral adrenalectomy for
  Cushings disease.
• 10 develop oral pigmentation
• Oral pigmentation like Addisons disease

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Ectopic ACTH production

• Rare
• Excess ACTH production by bronchial
  adenocarcinoma
• Oral hypermelanotic pigmentation similar to
  Addisons disease, but possible additional
  involvement of the soft palatal mucosa

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Chloasma

• Feature of late pregnancy
• Manifests as melanotic hyperpigmentation of the
  midface
• Involvement of the oral mucosa is extremely rare

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Albrights (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)

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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

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Haemochromatosis

• Investigations
• Elevated serum iron, reduced TIBC, elevated
  ferritin
• Iron in hepatocytes of biopsy

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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

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• Melanoacanthoma

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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 Addisons disease

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• Smokers Melanosis

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Drug-induced oral mucosal pigmentation

• Colours can be blue, brown, black, grey, green

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Drug-induced oral mucosal pigmentation

• Blue
• Amiodarone
• Antimalarials
• Bismuth (overdose)
• Mepacrine
• Minocycline
• Quinidine
• Silver
• Sulphasalazine

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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

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Drug-induced oral mucosal pigmentation

• Black
• Amiodaquine
• Betal nut
• Methyldopa

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Drug-induced oral mucosal pigmentation

• Green
• Copper
• Grey
• Amiodiaquine
• Chloroquine
• Fluoxetine
• Hydroxycholoquine
• Lead
• Silver
• Tin/zinc

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Local causes of oral pigmentation

• Ecchymoses
• Ephelis
• Melanoma and other malignancies
• Melanoacanthoma
• Naevus
• Melanotic macule
• Tattoos (amalgam, ink, graphite etc)

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Local causes of oral pigmentation - melanotic
macules

• Brown or black
• Usually affect lips or gingivae
• Arise at any age
• Not premalignant

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• Oral Melanotic Macule

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- 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

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tattoos

• Other tattoos include graphite pencil wounds and
  India ink tattoos
• Can reflect ritual (eg gingivae, lips)
• May reflect lifestyle
• Harmless

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• Amalgam Tattoo

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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

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Local causes of oral pigmentation -malignant
melanoma

• Oral disease is rare
• Malefemale ratio21
• Mostly in personsgt50 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

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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

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• Malignant Melanoma

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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 red-headed
  persons

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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

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Discoloration of teeth

• Extrinisic
• Smoking
• Beverages
• Drugs(iron, chlorehexidine, minocycline)
• Poor oral hygiene
• Betel chewing

• Intrinsic
• Tetracycline
• Fluorosis
• Amelogenesis imperfecta
• Kernicterus
• Porphyria

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