Pigmented Lesions (II/II)

Hypoadrenocorticism Melanosis associated

(Addison’s disease) with systemic or genetic disease

• Potentially life threatening disease (due to its under diagnosis)

• Etiology: decrease in endogenous corticosteroid levels due to autoimmune
disease (most common cause), adrenal gland infection (tuberculosis), trauma,
certain medications or idiopathic causes
Hypoadrenocorticism Melanosis associated
(Addison’s disease) with systemic or genetic disease

Image: http://www.organsofthebody.com/images/addison-disease.jpg accessed 10/11/2017

Hypoadrenocorticism Melanosis associated
(Addison’s disease) with systemic or genetic disease

• In some cases, oral melanosis may be

the first manifestation of their adrenal
disease
• Patchy brown pigmentations in the
labial mucosa of an individual with
Addison’s disease
Hypoadrenocorticism Melanosis associated
(Addison’s disease) with systemic or genetic disease

• Diagnosis:
• Skin bronzing
• Oral biopsy (increased melanin in the basal cell layer)
• Laboratory tests:
• Deceased serum cortisol and electrolyte levels
• Hyponatremia & Hypokalemia
 Hypoadrenocorticism Melanosis associated
(Addison’s disease) with systemic or genetic disease

Differential diagnosis of Hypoadrenocorticism Pigmentation

• Treatment: Exogenous steroid replacement therapy

 Exogenous
Amalgam Tattoo Pigmentation

• The most common pigmented lesion in the oral

mucosa is amalgam tattoo (1%–3% of the general
population)
• Etiology: Iatrogenic lesion that follows traumatic soft
tissue implantation of amalgam particles
• Clinical picture: lesions are typically small,
asymptomatic, macular, bluish grey or even black in
appearance and not changed appreciably over time
 Exogenous
Amalgam Tattoo Pigmentation

• Most common affected sites: They may be found on

any mucosal surface. However, it is seen more in the
gingiva and alveolar mucosa
• If the amalgam particles are of large size they may be
detected on radiograph

Image 1: http://www.rdhmag.com/articles/print/volume-23/issue-10/columns/case-study/case-10.html accessed 10/11/2017

image 2: https://classconnection.s3.amazonaws.com/107/flashcards/2728107/jpg/amalgam_tattoo_2-142CF9157164B6866BA.jpg accessed 10/11/2017
 Exogenous
Amalgam Tattoo Pigmentation

• More common with:

• Teeth with large amalgam restorations or crowned
teeth that probably had amalgams, around the apical
region of endodontically treated teeth
• Retrograde amalgam filling

http://www.exodontia.info/sitebuilder/images/Amalgam_Tattoo_behind_the_last_standing_tooth-518x363.png
 Exogenous
Amalgam Tattoo Pigmentation

Differential diagnosis of Amalgam Tattoo

Treatment: no treatment required, in some cases

may compromise esthetics; thus, surgical removal may be warranted
 Melanosis associated
Peutz-Jeghers Syndrome with systemic or genetic disease

• Etiology: Rare, autosomal dominant disease

(Pigmentation + intestinal polyposis)
• Multiple small macules usually measuring <0.5
cm in diameter in the perioral skin, lips, hands,
and feet.
• The lip and perioral pigmentation is highly
diagnostic
limited neoplastic
potential
intestinal polyposis abdominal pain
Rectal bleeding
Diarrhea
 Exogenous
Heavy Metal Pigmentation Pigmentation

• Some heavy metals (arsenic, bismuth, platinum, lead

and mercury) may be responsible for oral pigmentation
• Etiology: after occupational exposure to vapors of
lead
these metals
• These heavy metals may be deposited in both skin and
oral mucosa (especially in the gingiva)
• The characteristic color is gray to black and the
distribution is linear when found along the gingival margins
Copper
 Exogenous
Heavy Metal Pigmentation Pigmentation

• In the oral cavity, the pigmentation is usually found along the free marginal gingiva
• In some patients, the oral pigmentation may be the first sign of heavy metal
toxicity.
• Additional systemic signs and symptoms of heavy metal poisoning may include
• Behavioral changes
• Neurologic disorders
• Intestinal pain, and sialorrhea
 Exogenous
Heavy Metal Pigmentation Pigmentation

• Bismuth and lead staining of gingival tissue is known

as bismuth line and lead line, respectively

• Arsenic and bismuth compounds were used to treat Bismuth line

diseases such as syphilis, lichen planus, parasitic
infection and other dermatoses

• The underlying cause must be investigated because

of the risk of systemic toxicity lead line
 Focal Pigmented Lesion

Bluish-gray Macule Next Solitary Pigmented Solitary Pigmented

to an Amalgam Restoration Papule/Nodule Macule

X - ray
Location on the Gingiva,
Palate or Labial/Buccal Mucosa
Metallic Particles
Observed ?
Biopsy

No
Yes
Biopsy

Oral Melanotic Pigmented

Melanoacanthoma Melanoma
Amalgam Tattoo Macule Nevus
 Multi-Focal (diffuse) Pigmented Lesion

Individual of Individual of
Dark Complexion Light Complexion

Healthy?
Intake of medications Smoking Low Serum Cortisol Intraoral/
with melanogenetic Hyponatremia Perioral
Yes No potential Hypokalemia Macules
Yes
Yes
Physiologic Yes Intestinal
Pigmentation Polyposis
Smoker’s Addison’s
Melanosis Disease
Drug-Induced Yes
Melanosis
Peutz-Jeghers
Syndrome