GOOD MORNING

MAHARANA PRATAP DENTAL COLLEGE &

HOSPITAL

DEPARTMENT OF ORAL MEDICINE,DIAGONSIS AND

RADIOLOGY

Oral Pigmentation

Pigmentation is defined as the deposition of pigments in tissue or in oral mucosa.

• Augmentation of melanin production

• Increased no of melonocytes

• Deposition of accidently introduced exogenous materials

Causes

• ENDOGENOUS PIGMENTATION• FOCAL MELANOCYTIC PIGMENTATION• MULTIFOCAL/DIFFUSE PIGMENTATION• MELANOSIS ASSOCIATED WITH SYSTEMIC OR

GENETIC DISEASE• IDIOPATHIC PIGMENTATION• TREATMENT OF MUCOCUTANEOUS MELANOSIS• DEPIGMENTATION• HEMOGLOBIN AND IRON-ASSOSIATED

PIGMENTATION• EXOGENOUS PIGMENTATION

Classification

ENDOGENOUS PIGMENTATION

According to Burket’s

ORIGINATES FROM WITHIN THE BODYA) MELANIN PIGMENTATION: ‘MELAS’– BLACK• Endogenous, Derivative of tyrosine and is synthesized

by melonocytes ,which typically reside in the basal cell layer of the epithelium.

• Composed of eumelanin which is a brown-black pigment and pheomelanin which has red-yellow in color.

• It may be physiologic or pathologic and focal, Multifocal or diffuse in its presentation.

Endogenous Pigmentation

Freckle/Ephelis• The cutaneous freckle,or ephelis is a commonly

occurring,asymptomatic,small(1-3mm),well –circumscribed,tan-or brown-colored macule that is often seen in sun exposed regions of the facial and perioral skin.

• Freckle tends to become darker during periods of prolonged sun exposure and less during the winter & autumn month.

• Ephelis are most commonly observer in light skin individuals and are quit prevelant in red or light blond haired individuals.

• It is more abundant in no and darker in intensity during childhood and adolescence.

FOCAL MELANOCYTIC PIGMENTATION

EPHELIS (EPHELIDES/FRECKLES)

Treatment:-With increasing age,the number of ephelides and color intensity tends to diminish.In general no therapeutic intervention is required.

• The Melanotic macule is a unique,benign,pigmented lesion that has no known dermal counterpart.

• Most common oral lesion of melanocytic origin.

Oral/Labial Melanotic macule

• More frequent in females usually in the lower lip and gingiva.

• Lesion develop at any age but generally tends to present in adulthood.

• It tends to be small (<1 cm),well-circumscribed,oval or irregular in outline and often uniformly pigmented

• Overall,It is relatively innocuous lesion doesnot represent a melanocytic proliferation.

Clinical Features

Pathology

It is characterized by a normal epithelial layer.

Basal cells contain an abundance of melanin pigment without an increase in the number of melanocytes

• melanocytic nevus

• Malignant melanoma

• amalgam tattoo

• focal ecchymosis

Differential Diagnosis

• It is unsual,benign,melanocytic lesion.• It is an innocuous melanocytic lesion that may

spontaneously resolve,with or without surgical intervention.

• The term melanoacanthoma may imply a neoplastic process.

• The lesion is reactive in nature.• A biopsy is always warranted to confirm the

diagnosis,but once established no further treatment is required.

Oral Melanocanthoma

Oral Melanocanthoma

• It is usually present as a rapidly enlargement, ill defined, darkly pigmented macular or plaque-like lesion.

• Most develop in black females• It Occurs between 3rd and 4th decades of

life.• Typically asymptomatic, any mucosal

surface is involved,buccal mucosa is the most common site of occurrence.

• Borders are typically irregular.

Clinical Features.

• Oral melanocanthomas are characterized by a poliferation of bengin,

• Dendritic melanocytes through out the full thickness of an acanthotic and spongiotic epithelial layer.

• A mild lymphocytic infilterate with exocytosis is also characterstics.

• Occasionally esonophils may be seen.

Pathology

• Malignant melanoma

• Nevus and melanotic macule could also be consideration.

Differential Diagnosis

• It is arise as a consequence of melanocytic growth and proliferation.

• The intramucosal nevus is most frequently observed.

• The lesion nevus cells are cytologically and biologically distinct from melanocytes that colonize the basal cell layer of the epidermis and oral epithelium.

• Both genetic and environmental factors play a role in nevogenesis.

Melanocytic Nevus

Clinical features• Cutaneous nevi are a common occurrence.• The total number of nevi tends to be higher in males than

females.• Usually asymptomatic and often(<1cm),solitary,brown or

blue, well circumscribed nodule or macule• Most identified in pateints over the age of 30.• Common site followed by the buccal and labial mucosae

and gingiva.

Treatment:-Surgical excision is the treatment of choice for oral lesions.Laser and intense pulse light therapies have been used succesfully for the treatment of cutaneous nevi.

• It is the least common but most deadly of all primary skin cancers.

• Mostly common and a history of multiple episodes of acute sun exposure.

• Specially occurs at a young age, immunosuppression, the presence of multiple cuteanous nevi.

• It is prone in families have a high incideneof germ line mutations in the tumor supressor genes.

• Melanomas also frequently exhibit mutations in the BRAF,HRAS,and NRAS PROTO ONCO GENES.

Malignant melanoma

• Whites are mostly involved• High mortality rates are higher in blacks

and hispanics.• Male predilection but melanoma is most

commonly occurring in females of child bearing age.

• Cuteneous melanoma is more common in the sunbelt regions of the world.

CLINICAL FEATURES

• Physiologic pigmentation is the most common source of multifocal or diffuse oral mucosal pigmentation

• Common seen in dark-complexioned individuals,blacks ,asians and south africans.

• Generlized hyper pigmentation is seen.• Physiologic pigmentation is seen by

increased amounts of melanin pigment within the basal layer.

• Gingivectomy and laser therapy used to remove pigmented oral mucosa.

MULTIFOCAL/DIFFUSE PIGMENTATION

• Idiopathic• Drug Induced• Or Smoking-induced melanosis

Differential diagnosis

• Medication may induce a variety of different forms of mucocutaneous pigmentation,including melanosis.

• Cheif Drugs implicated in drug-induced melanosis are the antimalarial,including cholorquinone,hydroxychloroquine and others.

DRUG INDUCED MELANOSIS

• Has been Estimated 10 to 20% of all the acquired melanocytic pigmentation may be drug induced.

• Pigmentation seen in one mucosal surface,often the hard palate,or it can be multifocal and involve multiple surfaces.

• Sun exposure may excerbate cutenous drug induced pigmentation.

Clinical Features

• Diffuse melanosis of the anterior facial maxillary and mandibular gingivae,buccal mucosa ,lateral tongue,palate and floor of the mouth is occusionally seen among cigratte smokers.

• The mechanism by which smoking induce pigmentation is unknown.

• The oral meanosis increases first year of smoking and eventually it is reduced.

Smoker’s Melanosis

• Melasma is a relatively common,acquired symmetric melanosis that typically develops on sun-exposed areas of the skin and frequently on the face.

• Commonly affected areas forehead,cheeks,upper lips and chin.

• Distint female prediliction and most cases arise in darker-skkined individuals.

• The term melasma has been used to describe any form of generlized facial hyperpigmentation.

• A biopsy reveals basilar melanosis with no increase in the number of melanocyte.

• Melasma may spontaneously resolve after parturition,cessation of the exogenous hormones,or regulation of endogenous sex-hormone levels.

MELASMA(CHLOASMA)

• Hypoadrenocorticism(Adrenal Insufficiency,Addison’s Disease)

• Cushing’Syndrome/Cushing’s Disease• Hyperthyroidism(Graves’Disease)• Primary Biliary Cirrhosis• Vitamin B12(Cobalamin) Deficiency• Peutz-Jeghers Syndrome.• Cafe au Lait Pigmentation.• HIV/AIDS-Assosiated Melanosis.

MELANOSIS ASSOSIATED WITH SYSTEMIC OR GENETIC

DISEASE

Laugier-Hunziker PigmentationLaugier-Hunziker pigmentation was intially as an

acquired,idiopathic,macular hyperpigmentation of the oral mucosal tissues specifically involving the lips and buccal mucosae.

Patients typically present with multiple,discrete,irregularity shaped brown or dark brown oral macules.

Treatment:-laser and chemotherapy have been used with some sucess.

IDIOPATHIC PIGMENTATION

• Focally pigmented removal by diagonstic and therapeutic purposes.• Cases assosiated with neoplasia,surgical intervention is less of an

option for the treatment of multifocal or diffuse pigmentation.• Drug induced melanosis are subside after withdrawal of the

offending substance.• Laser therapy use in the treatment of bothersome oral pigmentation.

laser used:-superpulsed CO2 ,Q –Switched ND-YAG, and Q-Switched alexandrite lasers.

• First line of therapy is bleaching creams.Such as azelaic acid or hydroquinone have been used.

Most common,Dual-or triple-combination therapy is used.(combination of 4% hydroquinone-0.05% retinoic acid-

0.01% fluocinolone acetonide to be effective in greater than 90% of pateint.)

TREATMENT OF MUCOCUTANEOU MELANOSIS

VitiligoVitiligo is a relatively common, acquired,

autoimmune disease that is associated with hypomelanosis due to destruction of melanocytes.

Pathogenesis is multifactorial –genetic and environmental.

There maybe a single nucleotide polymorphism in a vitiligo-susceptibility gene that is also associated with susceptibility to other autoimmune diseases, including diabetes type 1, systemic lupus erythematous, and rheumatoid arthritis.

DEPIGMENTATION

• Ecchymosis

• Purpura/Petechiae

• Hemochromatosis

HEMOGLOBIN AND IRON-ASSOSIATED PIGMENTATION

• Traumatic Ecchymosis is common on the lips and face yet is common in the oral mucosa,except in cases related to blunt-force trauma and oral intubation.

• Ecchymosis of the oral mucosa may also be encountered in pateint with liver cirrhosis,leukemia,and end-stage renal disease undergoing dialysis treatment

Ecchymosis

Ecchymosis

• Oral Purpura/petechiae may develop as a consequence of trauma or viral or systemic disease.

• The distinction between purpura and petechiae is essentially semantic and based solely on the size of the focal hemmorrhages.

• Petechiae are typically characterized as being pinpoint or slightly larger than pinpoint and purpura as multiple,small 2 to 4mm collection of extravasated blood.

Purpura/Petechiae

• Hemochromatosis is a chronic,progressive disease that is characterized by excessive iron deposition in the liver and other organs and tissues.

• A lower labial gland biopsy has been shown to be easy and effective method for the diagnosis of hemochromatosis

Hemochromatosis

• Amalgam Tattoo• Graphite Tattoos• Ornamental Tattoos• Medicinal Metal-Induced Pigmentation• Heavy-Metal Pigmentation• Drug-Induced Pigmentation• Hairy Tongue

EXOGENOUS PIGMENTATION

Source of Exogenous oral and perioral Pigmentation.

According to Burket’s

Microscopically, particles are typically aligned along collagen fibers and around blood vessels

Amalgam Tattoo

• Occurs on the palate one to treatment

implantation of lead pencil

• Lesions are macular, focal gray or black

• Microscopically resembles amalgam.

Graphite Tattoo

Ornamental mucocutaneous tattooing is considered a rite of passage and esthetically pleasing. Female members of certain tribes are more likely to exhibit this form of exogenous pigmentation.

Ornamental Tatoos

A variety of metallic compounds have been used medicinally for the treatment of various systemic diseases.

Medicinal Metal-Induced Pigmentation

• Diffuse oral pigmentation may be assosiated with ingestion of heavy metals.Yet it remains an Occupational and health hazard for some individuals who work in certain industrial plant and for those who live in the environment in and around these types of facilities.

• Lead,mercury,bismuth,and arsenic have all been shown to be deposited in oral tissue if ingested over a extended period of time.

Heavy–Metal pigmentation

Heavy – Metal Pigmentation

Minocycline,which is a tetracycline derivative used in treatment of acne is a relatively cause of drug induced non-melanin-associated oral pigmentation.It causes pigmentation of developing teeth. developing teeth

Drug-Induced Pigmentation

Hairy tongue is a relatively common condition of unknown etiology.

Involves dorsum,especially middle and posterior one third of the tongue

Papillae are elongated which becomes pigmented

1) Colonization of chromogenic bacteria that imparts a variety of

colors ranging from green,brown,black

2) Various foods – Coffee, Tea

TREATMENT :

Patient is advised to brush the tongue and keep it clean.

Hairy Tongue

Hairy Tongue

Oral Pigmentation may be focal,mutifocal,or diffuse.The lesion may be blue,purple,brown,gray,or black. Some are Localized harmless accumulations of melanin,hemosiderin,or exogenous metal;orthers are systemic or genetic diseases,and some can be medical assosiated with life –threatening medical conditions.

Although Biopsy is a helpful and necessary aid in the diagnosis of focally pigmented lesions,the more diffuse lesions will require a through history and laboratory studies to arrive at a defintive diagnosis.

CONCLUSION

• Burket’s Oral Medicine 11th Edition.

• www.google.com.

Reference