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Oral Pigmentation

Oral Pigmentation. Melanocytes are pigment-producing cells that are derived from neural crest cells Melanin is formed from tyrosine by the action of tyrosinase

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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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