orofacial pigmentations ppt

1. PIGMENTATIONS

2. INTRODUCTION
• PIGMENTATION – Deposition of pigments in the tissues
CLASSIFICATION
• Physiologic
• Pathologic
• Exogeneous
• Endogeneous

5. FOCAL MELANOCYTIC PIGMENTATION
• Freckle/Ephelis
• Oral/Labial Melanotic Macule
• Oral Melanoacanthoma
• Melanocytic Nevus
• Malignant Melanoma

6. FOCAL MELANOCYTIC PIGMENTATION
Freckle/ephelis
• Commonly occurring, asymptomatic, small
(1–3 mm), well-circumscribed, tan- or
brown-colored macule that is often seen on
the sun-exposed regions of the facial and
perioral skin

7. ORAL/LABIAL MELANOTIC MACULE
• Melanotic macules - most common oral lesions
• Lower lip (labial melanotic macule) and gingiva
• Congenital melanotic macules - tongue
• Small (<1 cm), well-circumscribed,
• Oval or irregular in outline
• Uniformly pigmented

8. ORAL MELANOACANTHOMA
• Unusual, benign, melanocytic lesion that is unique
to the mucosal tissues
• Rapidly enlarging, ill-defined, darkly pigmented macular or plaque-like
• Asymptomatic, although pain has been reported
• Buccal mucosa - most common site
• Borders - typically irregular in appearance
• Pigmentation may or may not be uniform

9. MELANOCYTIC NEVUS
• No distinguishing clinical characteristics
• Asymptomatic , small (<1 cm), solitary, brown or blue, well
circumscribed nodule or macule
• Hard palate - most common site, followed by the buccal and labial
mucosae and gingiva.
• Malignant transformation of an oral nevus
has not been well documented in the literature

10. DIAGNOSIS
• Biopsy is necessary for diagnostic confirmation
Treatment
• Conservative surgical excision
• Laser and intense pulse light therapies
• Their value in the treatment of oral nevi
is unknown.

11. MALIGNANT MELANOMA
• On the facial skin, malar region - common site for melanoma
since this area is subject to significant solar exposure.
• Higher among black-skinned and japanese people
• More frequent in males than females.

12. • Palate - single most common site
• Maxillary gingiva - second most frequent site
• Oral melanomas have no distinctive clinical appearance.
• Macular, plaque-like or mass forming, well-circumscribed
or irregular and exhibit focal or diffuse areas of brown,
blue, or black pigmentation

13. • Ulceration, pain, tooth mobility or spontaneous exfoliation, root
resorption, bone loss, and paresthesia /anesthesia may be
evident.
• Tumors may be completely asymptomatic

14. DIAGNOSIS
• Whether the lesion is a primary neoplasm or a metastasis from a
distant site
• History of a previous melanoma, sparing of the palate and gingiva,
amelanosis
Microscopic features
• Lack of junctional activity and pagetoid spread –
suggestive of a Metastatic tumor

15. Management
• Primary oral melanomas- ablative surgery
• Adjuvant radiation therapy
• Immunotherapy

16. Multifocal/diffuse pigmentation
• Physiologic Pigmentation
• Drug-Induced Melanosis
• Smoker’s Melanosis
• Postinflammatory (Inflammatory) Hyperpigmentation
• Melasma (Chloasma)

17. PHYSIOLOGIC PIGMENTATION
• Multifocal or diffuse oral mucosal pigmentation
• Blacks, Asians and South-Americans - patchy to generalized
hyperpigmentation of the oral mucosal tissues - restricted to
gingiva
• Often observed in childhood
TREATMENT :
• Gingivectomy , laser therapy

18. SMOKER’S MUCOSAL MELANOSIS
• Tobacco smoking – major cause
• Tobacco smoke agents – melanocytes - melanin
• Women – more commonly affected because of synergistic
effect between female sex hormones and smoking
• Presentation : brown, gray or black areas
• Most common site: anterior labial gingiva,
interdental papilla of mandible
• Treatment : disappears within 3 years of smoking cessation.

19. ALCOHOL INDUCED PIGMENTATION
• Alcohol - increased oral pigmentation
• SITE: posterior regions of the mouth, soft palate
• Higher risk of cancers of the upper aerodigestive tract

20. DRUG INDUCED
• Due to synthesis and accumulation of
melanin pigments
• Deposition of drug or its metabolites
• Drugs : bleomycin , clofazinine,
chloroquine
• Presentation : diffuse brownish
discolouration of the hard palate,
gingiva, mucous membrane and tongue

21. • Minocycline - common cause of drug-induced non–
melanin-associated oral pigmentation.
• Surrounding bone - green, blue, black
• Palatal and alveolar mucosae - diffusely discolored

22. MELASMA (CHLOASMA)
• common, acquired symmetric melanosis that typically develops on
sun-exposed areas
• forehead, cheeks, upper lips, and chin - most commonly affected
areas

23. POST INFLAMMATORY (Inflammatory hyperpigmentation)
• Mucosa overlying a nonmelanocytic malignancy may become
pigmented
• Oral pigmentation with lichen planus (lichen planus
pigmentosus)
• Upon resolution of the lichenoid lesion,
the pigmentation may or may not disappear

24. EXOGENOUS PIGMENTATION
• Amalgam Tattoo
• Graphite Tattoos
• Ornamental Tattoos
• Medicinal Metal-Induced Pigmentation
• Heavy-Metal Pigmentation
• Drug-Induced Pigmentation
• Hairy Tongue

25. HEAVY METAL INDUCED
AMALGAM TATTOO:
Etiology and Pathogenesis
• Single most common source of solitary or focal pigmentation
• Iatrogenic in origin
• Consequence of the inadvertent deposition of amalgam
restorative material into the submucosal tissue.

26. CLINICAL FEATURES
• Small, asymptomatic, macular, and bluish gray or even black
• Gingiva, alveolar mucosa, buccal mucosa, floor of the mouth - most
common sites.
• Often found in the vicinity of teeth with
• Large amalgam restorations / crowned teeth
that probably had amalgams,
• Apical region of endodontically treated teeth with retrograde
restorations , Areas in and around healed extraction sites

27. MANAGEMENT
• If compromise esthetics - surgical removal
• No radiographic evidence of amalgam - biopsy is necessary.
Differential Diagnosis
• Melanotic macule,
• Nevus,
• Melanoma.
• Pigmentation associated with other dental restorative materials
• Titanium - dental implants - potential source of exogenous oral
pigmentation

28. GRAPHITE TATTOOS
• Unusual source of focal exogenous pigmentation
• Most common - palate
• Traumatic implantation of graphite particles from a pencil
• Solitary gray or black macule

29. MEDICINAL METAL-INDUCED PIGMENTATION
• Gold and colloidal silver - associated with diffuse
cutaneous pigmentation.
• Silver - generalized blue-gray discoloration (argyria)
• Gold-induced pigment - appear blue -gray or purple (chrysiasis)
• Pigmentation may be persistent, if not permanent
• Oral lichenoid eruptions have been associated with systemic
gold therapy

30. • Silver nitrate and zinc oxide - associated with focal
mucocutaneous pigmentation.
• Gray-black in appearance
• Generalized black pigmentation of the tongue - attributed to
the chewing of bismuth subsalicylate tablets

31. • Lead, mercury, bismuth, and arsenic have all been shown to be
deposited in oral tissue if ingested
• Free marginal gingiva - outlines the gingival cuff - gray to black
appearance.
• Mercury poisoning – Acrodynia /pink disease
• Affected children may show red cheeks and nose,
red lips, loss of hair, teeth, and nails, transient
rashes, hypotonia and photophobia

32. HAIRY TONGUE
• Common condition of unknown etiology
• Associated with chronic antibiotic therapy
• Involves dorsal tongue, particularly middle
and posterior one-third.
• Filiform papillae are elongated - appearance of fine hairs
• Hyperplastic papillae - pigmented by colonization of
chromogenic bacteria
• Foods, drinks, and confectionaries

33. Hemoglobin and iron-associated pigmentation
• Ecchymosis
• Purpura/Petechiae
• Hemochromatosis

34. ECCHYMOSIS
• Traumatic ecchymosis - common - lips and face
• Trauma - erythrocyte extravasation into the submucosa - bright
red macule or as a swelling if a hematoma forms – hemoglobin-
hemosiderin - brown coloration

35. PURPURA / PETECHIAE
• Appear red initially - brown in a few days
• PETECHIAE - pinpoint or slightly larger than pinpoint
• PURPURA - multiple, small 2 to 4 mm collections of extravasated blood
• Develop as a consequence of
• Trauma or viral or systemic disease
• Secondary to platelet deficiencies or aggregation disorders - Usually
not limited to the oral mucosa occur concomitantly on the skin.
• Viral disease - oral - soft palate (common)

36. HEMOCHROMATOSIS
• Oral pigmentation - diffuse and brown to gray
• The palate and gingiva are most commonly affected.

37. DEPIGMENTATION
Vitiligo
• Areas of depigmentation
• Common, acquired, autoimmune disease that is associated
with hypomelanosis
• Mechanisms remain unknown - destruction of the melanocytes

38. CLINICAL FEATURES
• Focal areas of depigmentation
• Vitiligo universalis
• Bilateral, symmetric areas of relatively generalized hypomelanosis
• Well-circumscribed, round, oval or elongated, pale or white-colored

39. MANAGEMENT
• Topical corticosteroids
• Systemic photochemotherapies (psoralen and ultraviolet A
exposure)
• Cutaneous bleaching
• Labial vitiligo –
• Autologous epithelial grafts
• Punch grafting and
• Micropigmentation

40. MELANOSIS ASSOCIATED WITH SYSTEMIC OR
GENETIC DISEASE

41. Melanosis associated with systemic or genetic disease
• Hypoadrenocorticism
• Cushing’s Syndrome/Cushing’s Disease
• Hyperthyroidism (Graves’ Disease)
• Primary Biliary Cirrhosis
• Vitamin B12 (Cobalamin) Deficiency
• Peutz-Jeghers Syndrome
• HIV/AIDS-Associated Melanosis

42. HYPOADRENOCORTICISM (adrenal insufficiency, addison’s disease)
Clinical features
• Weakness, poorly defined fatigue, and depression
• First sign of disease may be mucocutaneous hyperpigmentation
• Diffuse but patchy melanosis of the oral mucosa are hallmarks
• Any oral surface may be affected

43. DIAGNOSIS
• Requires a clinicopathologic correlation
• Endocrinopathic disease should be suspected whenever
oral melanosis is accompanied by cutaneous bronzing.

44. CUSHING’S SYNDROME/CUSHING’S DISEASE
Clinical features
• Characteristic “moon facies”
• Diffuse mucocutaneous pigmentation
• Pattern of oral pigmentation is essentially identical
(adrenal insufficiency)

45. HYPERTHYROIDISM (GRAVES’ DISEASE)
• Melanosis is a common consequence of hyperthyroidism
• 40% of black patients
• Very rarely observed in caucasian patients
• Tends to resolve following treatment of the thyroid abnormality
• The mechanism – remains unclear

46. PRIMARY BILIARY CIRRHOSIS
• Diffuse mucocutaneous hyperpigmentation - earliest
manifestations of primary biliary cirrhosis
• unknown etiology - thought to be autoimmune

47. VITAMIN B12 (COBALAMIN) DEFICIENCY
• Cutaneous and oral manifestations - generalized burning sensation and
erythema and atrophy of the mucosal tissue
• Diffuse mucocutaneous hyperpigmentation - rare complication
• Mechanisms - unknown
• Pigmentation resolves following restoration of vitamin B12 levels

48. PEUTZ-JEGHERS SYNDROME
• Autosomal dominant disease
• Intestinal polyposis, cancer susceptibility, and multiple, small,
pigmented macules of the lips, perioral skin, hands, and feet
• Macules - <0.5 cm in diameter
• Similar-appearing lesions develop on the
anterior tongue, buccal and labial mucosae
• Lip and perioral pigmentation is highly distinctive, although not
pathognomonic

49. HIV/AIDS -ASSOCIATED MELANOSIS
• Hyperpigmentation of the skin, nails, and mucous membranes
• Buccal mucosa - most frequently affected site
• Gingiva, palate, and tongue may also be involved

50. SYNDROMES ASSOCIATED…
• Familial atypical multiple mole and melanoma syndrome –
atypical nevi
• Epitheloid blue nevus – carney complex
• Common nevi – turner’s , noonan syndrome
• Cowden syndrome,cronkhite-Canada syndrome- GI
disease,pigmentation,cancer susceptibility
• Mc cune Albright syndrome
• LEOPARD syndrome
• Crowe’s sign – inguinal freckling
• Lisch nodules – pigmented lesions of iris

51. THANK YOU