Amalgam pigmentation (amalgam tattoo) of

the oral mucosa

A clinicopathologic study of 266 cases

Amos Buchner, D.M.D., M.S.D., * and Louis S. Hansen, D.D.S., MS., M.B.A.,**
San Francisco, Calif.
SCHOOL OF DENTISTRY. UNIVERSITY OF CALIFORNIA AT SAN FRANCISCO

A series of 288 cases of amalgam tattoo is analyzed both clinically and histologically. The most
common location was the gingiva and alveolar mucosa, followed by the buccal mucosa.
Histologically, the amalgam was present in the tissues as discrete, fine, dark granules and as
irregular solid fragments. The dark granules were arranged mainly along collagen bundles and
around blood vessels. They were also associated with the walls of blood vessels, nerve sheaths,
elastic fibers, basement membranes of mucosal epithelium, striated muscle fibers, and acini of
minor salivary glands. Dark granules were also present intracellularly within macrophages,
multinucleated giant cells, endothelial cells, and fibroblasts. Although in 45 percent of the cases
there was no tissue reaction to the amalgam, in 17 percent there was a macrophagic reaction and
in 38 percent there was a chronic inflammatory response, usually in the form of a foreign body
granuloma, with multinucleated giant cells of the foreign body and Langhans types. Asteroid bodies
were also found in some of the foreign body giant cells.

A malgam pigmentation, generally called amalgam

tattoo, is a relatively common finding in the oral mu-
cosa. The lesion representsembeddedamalgam parti-
cles and usually manifests itself as an isolated bluish or
black macule in various areas of the mucosa.‘, * Sur-
prisingly little information is available in the dental
literature on this lesion, and most textbooks of oral
pathology treat it only briefly and superficially, some-
times contradicting each other in describing its clinical
features and histomorphology .
The purpose of the present study is to analyze the
clinical features and histomorphologic variations of a
large series of casesof amalgamtattoo, in order to add
to our knowledge of this pathologic entity.
MATERIALS AND METHODS
The files of the Oral Pathology Diagnosis Service of
the University of California, San Francisco, School of
Dentistry served as a source of material for this study.
All cases coded as amalgam pigmentation, amalgam
*Visiting Associate Professor, Division of Oral Pathology, Depart-
ment of Oral Medicine and Hospital Dentistry.
**Professor and Chairman, Division of Oral Pathology, Department
of Oral Medicine and Hospital Dentistry.
0030-4220/80/020139+09$00.90/00 1980 The C. V. Mosby Co.
tattoo, and localized argyrosis between Jan. 1, 1969,
and Nov. 15, 1978, were retrieved from the files. Only
pigmented lesions of soft tissue were included in the
study. Casesof amalgampigmentation associatedwith
periapical granulomasor radicular cysts were excluded.
Lesions which appearedclinically not as pigmented le-
sions but as, for example, white keratoses(leukoplakia)
or irritation fibromas, and yet histologicaHy exhibited
some features similar to those of amalgam pigmenta-
tion in addition to the features of the primary lesions,
were also excluded from the study. Thus, of the 297
specimensretrieved and reviewed, only 268 acceptable
casesof amalgam tattoo remained for analysis.
During the period from which the 268 cases were
retrieved, there were 20,731 surgical specimensin the
tissue diagnosis service, and thus the amalgam tattoo
accounts for 1.3 percent. During this sameperiod, we
had diagnosed 105 cases of melanotic macule of the
oral mucosa (0.5 percent)3and 32 casesof pigmented
nevus of the oral mucosa (0.15 percent)? ’
RESULTS
Location
Table I shows the location of the amalgam tattoos.
Almost half (47.8 percent) were located on the gingiva
139
140 Buchner and Hansen Oral Surg.
February, 1980

Table II. Age distribution of patients with amalgam

tattoo
Age group No. of cases Percent of cases

o-9 0 0
10-19 12 4.6
20-29 49 18.8
30-39 53 20.3
40-49 57 21.8
50-59 43 16.5
60-69 28 10.8
70-79 16 6.1
80-89 - 3 1.1
Total 261 100.0

Table ill. Size of amalgam tattoos

Size range (cm.) No. of cases Percent of cases

Fig. 1. A macule of amalgamtattoo in the buccal mucosa. 0.1-0.3 77 46.4

0.4-0.6 54 32.6
0.7-0.9 II 6.6
Table I. Location of amalgam tattoo I -1.2 I6 9.6
Location No. of cases Percent of cases I .3 and above 8 4.8
Total 166 100.0
Gingiva 76 28.4
Mandible 45
Maxilla 31
Alveolar mucosa 52 19.4
Table IV. Duration of amalgam tattoo
Mandible 40 Duration No. of patients Percent ofpatients
Maxilla 12
Retromolar area 14 5.2 “Several months”* I8 27.7
Mucobuccal fold 21 7.8 “Several years”? 38 58.5
Mandible 16 “Many years”+ 9 13.8
Maxilla 5 Total 65 100.0
Buccal mucosa 61 22.8
Floor of mouth 23 8.6 *Including specific duration of 2 to I1 months.
Tongue 9 3.4 tlncluding specific duration of I to 9 years.
Hard palate 2 0.7 Slncluding specific duration of 10 years and over.
Soft palate 3 1.1
Labial mucosa 7 2.6 172 (65 percent) were female and 94 (35 percent) were
Lower 5 male. The ratio of females to males was 1.8 : 1.
Upper 2
The race of 252 patients was known. Almost all of
Total 268 100.0
the patients were white (241 or 96 percent). Five were
Asian, and the remainder were black, Hispanic, and
and alveolar mucosa, the mandibular region being af- American Indian (two of each).
fected more than the maxillary region. The buccal mu-
cosa was the next most common location (22.8 per- Clinical features
cent), followed by the floor of the mouth (8.6 percent) The amalgam tattoo was usually described by the
and the mucobuccal fold (7.8 percent). Lesions were clinicians as a “flat macule,” although in certain cases
also found in the mandibular retromolar area, tongue, it was described as a “slightly raised lesion” (Fig. 1).
labial mucosa, and hard and soft palate. The margins were described as “well defined” for
some lesions and as “irregular” or “diffuse” for
Age, sex and race others. The color was usually described as black, blue,
The age at time of excison was known for 261 gray, or a combination of these.
patients, and the age distribution is shown in Table II. In 15 patients (5.6 percent) the lesion was not soli-
The age range of the patients was 12 to 82 years, and tary and there was a history of two or more similar
the mean age was 43.1 years. Sixty-one percent of the lesions in the oral cavity.
patients were between the ages of 20 and 49. The size of the lesion was known in 166 cases (Table
The sex was known for 266 patients and, of these, III) and ranged from 0.1 to 2.0 cm. Almost half of the
Volume49
Number2
Fig. 2. Low magnification of amalgam tattoo exhibiting solid massesof amalgam in the connective tissue
(Hematoxylin and eosin stain. Magnification, x 100.)
lesions were from 0.1 to 0.3 cm., and almost one third
were from 0.4 to 0.6 cm. in their greatest diameter.
Only a few lesions (4.8 percent) were larger than 1.2 cm.
In 65 cases there was some information regarding the
duration of the lesion (Table IV). Since these data do
not represent the true duration of the lesion but, rather,
the time when the patient or the dentist first noticed the
lesion, their value is very limited.
Most of the lesions were asymptomatic and were
discovered during routine dental examination. Sixteen
Amalgam pigmentation of oral mucosa 141
patients, however, had complained that the lesion had
gradually increased in size.
Roentgenographic information was given in 37
cases. In 10 cases it was positive and the clinic :ians
described tiny radiopaque areas, whereas in 27 cas,es it
was completely negative.
Clinical diagnosis
A variety of clinical diagnoses had been made., but
the most common was amalgam tattoo. Of the 244
142 Buchner and Hansen
Fig. 3. Low magnificationof amalgamtattooexhibiting fine particlesalongcollagenbundlesandaroundsmall
blood vessels.(Hematoxylinandeosinstain. Magnification,x 100.)
clinicians who made a clinical diagnosis, 182 (74.6
percent) gave amalgam tattoo as their first choice.
Thirty-two (13.1 percent) gave focal melanosis, 28
(11.5 percent) gave pigmented nevus, and 2 (0.8 per-
cent) gave thrombosedvarix as their first choice for the
clinical diagnosis. Seventy-threeclinicians (30 percent)
requestedthat malignant melanoma be ruled out.
Histomorphologic features
Distribution of the amalgam in the tissues. The
amalgam was present in the tissues in two forms, as
numerous discrete, fine, black or dark brown granules
and as irregular dark, solid fragments of various sizes.
The granules varied only slightly in size and shape,
were for the most part round, and measuredbetween
0.5 and 1.0 microns. Occasionally granules were mat-
ted together in large clumps. In 89 cases(33.2 percent)
the amalgam was present only in the form of granules,
while in 179 cases(66.8 percent) it was present in both
forms.
The amalgam granules and fragments were found
mainly in the lamina propria but were sometimesseen
Oral surg.
February: 1980
in the submucosa.Granules were seen even in deeper
tissues, such as striated muscle. In no case, however,
were granules found in the mucosal epithelium.
The amalgam fragments were scatteredhaphazardly
in the connective tissue, but the granules, in addition to
being diffusely scattered,were often also arrangedin a
chain-like fashion along collagen bundles and around
small blood vessels(Figs. 2 to 4). Less frequently, but
still commonly, the granules were found to accumulate
in the walls of blood vessels of various sizes and in
nerve sheaths and to be associatedwith elastic fibers
and the basementmembraneof the mucosalepithelium.
In a few casesthe granules were present in the connec-
tive tissue between individual muscle fibers (en-
domysium) and in the connective tissue surrounding
acini of minor salivary glands. They were also ob-
served within macrophages,multinucleated giant cells,
endothelial cells, and fibroblasts.
In many lesions there was, in addition to the dark
granules which lined the collagen bundles, a homoge-
nous golden-brown staining of coarsefibers, the nature
of which could not be identified. The golden-brown
Volume
Fig. 4. High magnificationof amalgamtattooexhibiting discrete,fine, dark granulesalong collagenbundles
(Hematoxylinandeosinstain. Magnification,x250.)
color was also present in unstained slides; therefore, it
was not associated with the staining procedure but,
rather, with the amalgam pigmentation.
In several cases, in spite of the clinical picture of a
bluish lesion, the granules were so fine that low-power
microscopic examination offered no explanation for the
clinical discoloration. Only high-power examination
revealed the numerous fine dark granules responsible
for the bluish color.
Tissue reaction to the amalgam. There was usually
no tissue reaction in the lesions containing only fine
granules of amalgam, but there were varied reactions in
lesions containing both granules and fragments. Of the
89 casesinvolving only fine granules, 12 caseshad a
few areas in which macrophages(3 cases) or a mild
chronic inflammatory infiltrate (9 cases) surrounded
heavy clumps of granules.
No inflammatory reaction was seenin 43 of the 179
casesinvolving both granules and fragments of amal-
gam. In another43 casesthere was somefocal reaction;
the fragments were surroundedby macrophages,but no
Amalgam pigmentation of oral mucosa 143
other mononuclear inflammatory cells were present.
Actually, under low-power microscopic examination,
the amalgam massesappearedto be located within the
lumen of blood vessels, and only under high mag-
nification was it clear that the fragments were sur-
rounded by one to several rows of macrophages.In six
cases of this group, the macrophages seemed to be
fused, forming multinucleated giant cells.
In the remaining 93 cases,there was a focal chronic
inflammatory reaction to the amalgam pieces. The
inflammatory responsewas usually mild to moderate,
and while sometimes it had no specific architecture,
most of the time it took the form of a granuloma of the
foreign body type (amalgam granuloma). The inflam-
matory reactions covered a wide spectrum, ranging
from lesions in which the fragments were surrounded
by an abundanceof lymphocytes and small thin-walled
blood vesselsbut only a few macrophagesto lesions in
which the fragments were surrounded mainly by mac-
rophages, giant cells, and fibroblasts but only a few
lymphocytes (Figs. 5 and 6). Multinucleated giant
144 Buchner and Hansen
Fig. 5. Amalgam fragments surroundedby an abundanceof lymphocytes and a few macrophagesand giant cells
(Hematoxylin and eosin stain. Magnification, x 100.)
cells, engulfing pieces of amalgam, were present in 36
lesions of the latter group. Many of these cells also
contained fine dark granules in their cytoplasm, and a
few contained small pieces of amalgam. Most of the
giant cells were of the foreign body type, but cells of
the Langhans type were also found (Fig. 7). In five
cases, the giant cells contained stellate-shaped inclu-
sions commonly known as asteroid bodies (Fig. 8).
DISCUSSION
Although some textbooks of oral pathology have
stated that amalgam does not evoke an inflammatory or
Oral Surg.
February,1980
giant cell response, our study has shown that, in fact,
there is a wide histomorphologic spectrum of tissue
response to dental amalgam.
Although in 45 percent of the cases there was no
tissue reaction to the amalgam, in 17 percent there was
a macrophagic reaction and in 38 percent there was a
chronic inflammatory response, usually in the form of a
foreign body granuloma (amalgam granuloma).
Giant cells of either the foreign body or Langhans
type, which were observed in our study, are commonly
found in foreign body granulomas .6 The observation of
a third type of giant cell with asteroid bodies, similar to
Volume
Number
Fig. 6. Amalgam granulomas composedmainly of macrophagesand multinucleated giant cells engulfing frag-
ments of amalgam. (Hematoxylin and eosin stain. Magnification, x80.)
that found in sarcoidosis, was of interest. However, it
is known today that the star-shaped bodies are not
specific for sarcoidosis, as they have been described in
other granulomatous diseases, such as tuberculosis,
leprosy, berylliosis, and histoplasmosis,’ as well as in a
case of amalgam tattoo.s Azar and Lunardellis have
shown that the asteroid bodies consist of collagen
showing the typical 64 to 70 nm. periodicity and state
that probably the collagen is trapped between macro-
phages during the stage of giant cell formation. Accord-
ing to Lever and Schaumberg-Lever,6 the occasional
presence of asteroid bodies within a foreign body
granuloma is not specific for any disease.
Some oral pathologists use the term localized ar-
gyrosis as a synonym for amalgam tattoo. Although
there are histopathologic similarities between amalgam
tattoo and argyria of the skin,‘0-‘2 the use of this term
for oral lesions is not accurate since amalgam is com-
posed mainly of mercury, silver, and tin. Harrison and
associates13used electron-probe microanalysis to exam-
ine sections of amalgam tattoo and showed that, with
time, corrosion occurs, and mercury and some tin are
Amalgam pigmentation of oral murosa 145
lost from the tattoos. However, silver and tin remain,
both extracellularly and intracellularly, within macro-
phages and giant cells. Hence, the term localized ar-
gyrosis, which relates only to silver, is technically not
accurate and we suggest that the term amalgam pig-
mentation or amalgam tattoo be used.
Amalgam tattoo is caused by introduction of dental
amalgam into soft tissue. Amalgam may be introduced
in several ways during restorative and surgical proce-
dures:
1. It may be condensed in abraded gingiva during
routine amalgam restorative work.
2. It may enter mucosa lacerated by rotary instru-
ments during removal of old amalgam fillings or crown
and bridge preparation of teeth with large amalgam
restorations.
3. Broken pieces may be introduced into a socket or
beneath the periosteum during extraction of teeth.
4. Particles may enter a surgical wound during root
canal treatment with a retrograde amalgam filling.
In some of our cases, the amalgam tattoo increased
in size with time. One explanation for this may be that
146 Buchner and Hansen
Fig. 7. Amalgam granuloma with giant cells of the foreign body and Langhans type. (Hematoxylin
stain. Magnification, x250.)
macrophages,giant cells, and perhaps tissue fluids are
capable of slowly breaking down the amalgam frag-
ments. As a result, large numbersof dark granules may
be found within the cytoplasm of cells which are also
capable of moving toward the periphery, thus increas-
ing the clinical size of the lesion. Another factor which
may explain the increase in size of lesions could result
from the inclusion of amalgamfragments in the socket
of an extracted tooth. Over the years, the edentulous
alveolar ridge is gradually resorbed, bringing the amal-
gam particles closer to the surface of the alveolar mu-
cosa. Thus, the lesion appearsclinically to be progres-
sively increasing in size.
The bluish black discoloration of the amalgamtattoo
is clinically similar to other focal pigmented lesions of
the oral mucosa and thus must be differentiated from a
pigmented nevus (ordinary or blue), oral melanotic
macule, malignant melanoma in situ, and malignant
melanoma.3-5 Although amalgam tattoo can often be
diagnosedclinically with ease, sometimesit cannot be
visually differentiated from other pigmented lesions.
Oral Surg.
February, 1980
and eosin
Radiographically, the presence of opaque particles at
the site of a lesion establishes the diagnosis, but in
many casesthese particles are too small or too diffuse
to be demonstrated.In fact, radiographs will be nega-
tive except when gross fragments of amalgam are pre-
sent in the tissue.
Amalgam tattoos do not require treatment. However,
failure to demonstrate radiopaque particles on roent-
genographs, especially in the case of suspicious le-
sions, requires a biopsy to rule out other pigmented
lesions of a more serious nature. Biopsy should also be
performed if the patient or dentist is concerned about
the exact nature of the pigmented lesion.
The authors would like to thank Dr. John B. Ferris for the
clinical picture (Fig. I), Evangeline Leash for editorial assis-
tance, and Maryam Coen and Teresita Arenas for typing the
manuscript.
REFERENCES
1. Orban, B.: Discoloration of the Oral Mucous Membrane by
Metallic Foreign Bodies, J. Periodontal. 17: 55-65, 1946.
Volume 49 Amalgam pigmentation of oral mucosa 147
Number 2

Fig. 8. Amalgam granuloma with foreign body giant cells containing asteroid bodies. (Hematoxylin and eosin
stain. Magnification, x250.)

2. Weathers, D. R., and Fine, R. M.: Amalgam Tattoo of Oral Bodies of Giant Cells in Sarcoidosis,Am. J. Pathol. 57: 81-92.
Mucosa, Arch. Dermatol. 110: 727-728, 1974. 1969.
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Mucosa: A Clinicopathologic Study of 32 New Casesand Re- M. A.: Argyria: Electron Microscopic Study of a Case, Br. J.
view of 75 Cases From the Literature. Part I, ORAL SURG. 48: Dermatol. 78: 175-179, 1966.
131-142. 1979. 12. Pariser, R. J.: Generalized Argyria: Clinicopathologic Features
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view of 75 CasesFrom the Literature. Part II, ORAL SURG. (In 13. Harrison, J. D., Rowley, P. S. A., and Peters, P. D.: Amalgam
press.) Tattoos: Light and Electron Microscopy and Electron-Probe
6. Lever, W. F., and Schaumberg-Lever,G.: Histopathology of the Micro-Analysis, .I. Pathol. 121: 83-92, 1977.
Skin, Philadelphia, 1975, J. B. Lippincott Company, p. 55.
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Review of Three Hundred Cases,Including Twenty-two Autop- Dr. Louis S. Hansen
sies, Am. J. Clin. Pathol. 19: 725-749, 1949. Division of Oral Pathology
8. Simon, E., Buchner, A., and Bubis, J. J.: Asteroid Bodies in School of Dentistry, Room 524-S
Foreign Body Reaction to Amalgam, ORAL SURG. 33: 772-774, University of California
1972. San Francisco. Calif. 94143
9. Azar, H. A., and Lunardelli, C.: Collagen Nature of Asteroid