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Oral Pigmentation

Oral pigmentation results from melanocytes producing melanin, influenced by various factors. This pigmentation can be congenital or acquired, benign or malignant, and endogenous or exogenous. Common causes include racial pigmentation, naevi, and drug effects. Physiological and pathological conditions, like Addison’s disease and neoplastic processes, contribute to diverse pigmentation patterns ranging from brown to black or blue. Different types of oral pigmentation, including freckles and lentigines, present unique clinical features that aid in differential diagnosis and understanding of underlying conditions.

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Oral Pigmentation

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  1. 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.

  3. Etiology • Congenital or acquired • Benign or malignant • Endogenous or exogenous

  4. 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

  5. Benign causes of oral pigmentation • Physiologic pigmentation • Ephelides • Lentigo • Oral melanotic macule • Smoking melanosis • Intraoral nevi

  6. Malignant causes of oral pigmentation • Melanoma • Neuroectodermal tumor of infancy

  7. Endogenous causes • Postinflammatoty hyperpigmentation • Melanoacanthoma • Addison’s syndrome • Peutz- Jegher’s syndrome • Laugier-Hunziker syndrome

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

  9. 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

  10. Racial pigmentation Differential diagnosis: • Addison’s disease • Albright’s Syndrome • Heavy metal pigmentation • Use of antimalarial drugs

  11. 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.

  12. 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.

  13. 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.

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

  15. 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.

  16. 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.

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

  18. Endocrinopathies causing oral pigmentation • Addison’s disease • Nelson’s syndrome • Ectopic ACTH production • Pregnancy

  19. 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

  20. 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

  21. 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

  22. 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

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

  24. 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)

  25. 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

  26. Haemochromatosis • Investigations: • Elevated serum iron, reduced TIBC, elevated ferritin • Iron in hepatocytes of biopsy

  27. 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

  28. Melanoacanthoma

  29. 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

  30. Smoker’s Melanosis

  31. Drug-induced oral mucosal pigmentation • Colours can be blue, brown, black, grey, green

  32. Drug-induced oral mucosal pigmentation • Blue • Amiodarone • Antimalarials • Bismuth (overdose) • Mepacrine • Minocycline • Quinidine • Silver • Sulphasalazine

  33. 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

  34. Drug-induced oral mucosal pigmentation • Black • Amiodaquine • Betal nut • Methyldopa

  35. Drug-induced oral mucosal pigmentation • Green • Copper • Grey • Amiodiaquine • Chloroquine • Fluoxetine • Hydroxycholoquine • Lead • Silver • Tin/zinc

  36. Local causes of oral pigmentation • Ecchymoses • Ephelis • Melanoma and other malignancies • Melanoacanthoma • Naevus • Melanoticmacule • Tattoos (amalgam, ink, graphite etc)

  37. Local causes of oral pigmentation - melanotic macules • Brown or black • Usually affect lips or gingivae • Arise at any age • Not premalignant

  38. Oral Melanotic Macule

  39. - 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

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

  41. Amalgam Tattoo

  42. Local causes of oral pigmentation - bacillary angiomatosis • Rare • Usually a feature of HIV disease • Caused by Bartonellaquintana or Bartonellahenselae • Gives rise to pigmented nodules • Can affect the skin, bone and liver • Responds to erythromycin

  43. 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

  44. 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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