Pigmented Oral Lesions PDF

Dr. Hala Helmi A. Hazzaa Professor of Oral Medicine, Diagnosis, Periodontology Al-Azhar University for girls  Pigmented oral lesions Hala H Hazzaa  Color Origin Cause Hala H Hazzaa  Esthetic problem...

Dr. Hala Helmi A. Hazzaa Professor of Oral Medicine, Diagnosis, Periodontology Al-Azhar University for girls  Pigmented oral lesions Hala H Hazzaa  Color Origin Cause Hala H Hazzaa  Esthetic problem Systemic Ds Undiagnosed malignancies Why??? Hala H Hazzaa Hala H Hazzaa Pigmentation of the oral mucous membrane are either: Exogenous Endogenous: Not formed in the body e.g. 1. Direct deposition into the sub-mucosa directly Pigments are synthesized in e.g.; (Graphite) giving the body e.g. (gray or black). metalintoxication 2. I n g e s t e d p i g m e n t 1. Hemoglobin (blue, red (Carotinemia) or purple). 3. Chromogenic bacteria 2. Hemosiderin or (brown) (black, brown or green). 3. Melanin (brown, black 4. Precipitated in the C.T. or gray). (during smoking) Hala H Hazzaa  vascular lesion or transportation Hemoglobin: Iron containing, oxygen transport, redmetaloprotein. The pigment Hemosiderin: blue appearance onIron is red or thestorage mucosacomplex and or ferritin represents pigmentation associated complex, appears brown and is Melanin: with vascular lesions deposited as a consequence of bloodin a specialized pigment is produced extravasation, it may group of occur as a as melanocytes cells known consequence Melanin of trauma or a a plays defect in protective role (melanin extravasation hemostatic mechanisms. synthesis consumes any oxygen excess) of blood so dark skinned people are less liable to certain skin diseases. Hala H Hazzaa Burkitt’s classification 1996: 1-puple blue vascular pigments. 2-brown melanin/ brown heme pigments. 4-grey/black pigments. Hala H Hazzaa Multiple  Hereditary hemorrhagic telangiectasia  Kaposi's sarcoma  Hemangioma Focal  Varix Hala H Hazzaa   Physilogic pigmentation  Pigmented lichen planus  Drug induced melanosis Multiple  HIV-oral melanosis  Cafe au lait pigmentation  Petechiae and ecchymosis  Endocrinopathic Pigmentation  Peutz-Jegher’s Syndrome  Nevus Focal  Melanoma  Melanotic macule Hala H Hazzaa Multiple  Hairy tongue  Heavy metal toxicosis  Amalgam tattoo Focal  Graphite tattoo Hala H Hazzaa  Brown Melanotic Lesions: o Melanin is the pigment derivative of tyrosine. o It is synthesized in melanocytes that transfer melanin granules into adjacent basal cells to protect against the damaging effects of actinic irradiation. unction of Melanin: 1)Skin: Melanin has protective function. s -White people are more susceptible to skin cancer. -The process of melanization consumes any released noxious oxygen in the tissues. 2)Eye: so It acts as light proof so give sharp vision and give the color of the eye. 3)Hair: The color of hair is due to types of melanin present in the hair pulp and cortex. Hala H Hazzaa  These contain tyrosinase, which hydroxylates tyrosine to dihydroxy-phenyl-alanine (dopa), which converted to melanin within melanosomes. Grosinase HB A melanocyte and the production of melanosomes Hala H Hazzaa  Increased melanin production occurs in: 1- Increased sun exposure in basal cell layer 2- Drugs 3- Increased pituitary hormone (ACTH) 4- Mechanical factors e.g: trauma 5- Chemical factors e.g: perfume 6- Benign and malignant melanoma -Itevolves usually in childhood & doesn’t arise in adulthood. ntmw Gsrecentl y Tndooine id -Significance: jo IT Any multifocal or diffuse pigmentation of recent onset (without cause or drug)…. …. More investigations are indicated to rule out any abnormalities or endocrinopathic disease monocycline drug Hala H Hazzaa Abnormal clinical presentation of physiologic pigmentation Normal physiologic pigmentation Hala H Hazzaa  Infiltration of T-lymphocytes Toed into the basale cell even layer are expected to stimulate melanogenesis f & contribute to such pigmentation. Etiology CP occurs in basal cell space of melanocyte which Hala H Hazzaa layer this affected  secreted of melanen h e n lic t e d e n u s m n Pig pla Hala H Hazzaa Definition: it a rare syndrome characterized by; 1) Autosomal inheritance. not_sex 8 G 2) Mucocutaneous melanin pigmentation. both 3) Gastrointestinal polyps. Clinically: v Brown or black melanotic macules on: o t Skin of feet, hands, Oral buccal mucosa, circumoral & lips, gingiva & tongue. circumnasal. 1-10 mm in diameter. v Intestinal polyps that may lead to: Episodes of abdominal pain, hemorrhage, obstruction or duodenal carcinoma. Judinalcarcinomac Hala H Hazzaa ristlof.I I  u s e o a n sis : u t re no c. t a ag o io n t h a a D i c t s m M u enta l y p e ne 1) m l p o um ig p tina a ri t e s b y b eal. I wn m m 2) o sh ariu or b Hala H Hazzaa  TED -It’s usually encountered with Addison’s disease as steroid hormones, the feedback loop is stimulated with excess secretion of ACTH -Why? suptarenalgland pituta ryg landcortiscijay b Effect of the melanocyte-stimulating hormone (MSH) …. Increased melanin accumulation A -Clinically: j1 j enough Bronze skin + patcy melanosis of oral mucosa e.g. gingiva, palate, buccal mucosa. -This type of pigmentation is reversible??? Hala H Hazzaa  Addison’s disease intra-oral pigmentation Hala H Hazzaa -It’s diffuse macular melanosis occurs in some smokers, with a non premalignant potential. -Common site: buccal mucosa, lateral tongue, palate, floor of the mouth. -Etiology: it may be attributed to stimulation of melanogenesis by tobacco smoke products. v The intensity of pigmentation depends on the duration & amount of smoking Hala H Hazzaa Smoker’s melanosis develops mainly on attached gingiva Tatooter Hala H Hazzaa  in -They are due to benign proliferations of melanocytes. -There are two major types based on histology & clinical features: Nevocellular nevi (junctional nevi) Biopsy is necessary for diagnostic confirmation,,,,Why?? The blue nevus -Since the clinical diagnosis includes many other focal oThey arise from basal melanocytes early in life. pigmentations oThe nevus cells such as melanotic remain macule, the basal layer, melanoma, at the and junction of the oIt is blue tattoo. amalgam in color because theonmelanocytes reside deep in the epithelium and underlying connective floor tissue. connective tissue and the overlying vessels dampen the brown oThey are macular, flat, have a regular outline, round or oval in coloration of melanin and give a blue tint. shape, homogenous brown color and once reach certain size, growth stops -Simple and is excision lesion remains static. the treatment of choice. round Hala H Hazzaa oval to  O o w̅ jfbgbloodvesselws.IE jfhs  _m -Many drugs can induce oral mucosal pigmentation e.g.; -Minocycline (used in treatment of acne). I -Oral contraceptives. ‫ٮﻊ اﻟﺤﻤﻞ ﻋﻦ ﻃريﻖ‬- ‫وﺳﺎﺋﻞ ﻣ‬ et.ua These pigmentations can be: 1. Localized, usually to the hard palate. 2. Multifocal, throughout the mouth. Sometimes extra-oral pigmentation may also occurs e.g.; facial skin, particularly the periorbital and perioral regions. oral contraceptives move cyclens Hala H Hazzaa Drug-induced melanosis; due to the direct stimulatory effect of certain drugs on melanocytes Hala H Hazzaa -Mostly, it occurs in macular form in buccal mucosa , but it can occur elsewhere. -Why? affeetsupta.ve gland HIV- seropositive patients with opportunistic infections may have adreno-cortical involvement by a variety of parasites. Addison’s disease manifestations Hala H Hazzaa rare in oral cavity skin mainly Cutaneous melanomas It is more aggressive Mucosal melanomas 1. Site: it occur mostly on the 1. It’s extremely rare. malar region of the face 2. Common sites: anterior (as a result of solar gingiva or palate. exposure). 3. Brown/black in color. 2. Clinically, early it appears 4. Excision is indicated macular (good prognosis). (with safety margin), 3. Late, it becomes nodular when nodularity is & exhibit irregular margins encountered. (not smooth like in case of nevi……D.Diagnosis). Hala H Hazzaa  t en fer if i n d o ma lan a re e py r a l m rity. r a t r a - o f sev e o the I n es o g h em sta c i o n & d i a t ve. R a fecti f ine Hala H Hazzaa -Cafe au Lait Pigmentation is usually seen in this disease. -Thepresence of "café au lait“ pigmentation (the color of coffee with cream), that vary from small freckle like macules to broad diffuse lesions. -They tend to appear in late childhood & can be multiple overling the neurofibromatous swellings on the skin. -Multiple neural tumors are possible. -Rarely: oral pigmentation is encountered. Hala H Hazzaa  mainly skin Very rare oral Him cavity Cafe au Lait Pigmentation Hala H Hazzaa  α Hala H Hazzaa Images of a person with McCune- Albright syndrome (MAS) with distinct malformations of the face & the appearance of teeth. Hala H Hazzaa vBrown Heme-Associated Lesions: 1. Ecchymosis 2. Petechia 3. Hemochromatosis Hala H Hazzaa Red or purple trauma drug causebpettgggm.ae Purpura: is a general term describes any disease which produce abnormal bleeding tendency (3–10 mm). Petechiae: occurs secondary to platelet deficiency or clotting disorders are not limited to oral mucosa but occur also on skin (pin point in size) (≤ 3 mm). Tooooo Ecchymosis: occurs mainly due to traumatic injury (traumatic ecchymosis common on lips) & abnormal hemostatic function (larger than petechiae) (≥ 1 cm). Healing occurs within 1-2 weeks in case of trauma. If no Hx of trauma, bleeding disorders should be expected. e I N.B. hematoma results from injury to large vessel. s Hala H Hazzaa  Petechiae & ecchymosis Hala H Hazzaa  IR.IT they pressurethere is no change lesion µ bleedingwithin EX tissues vascular IsII abnormality Petechone bloodvesselsdilated chymosis likeinhemangiom ballergy __balchingwithpku s adjacentIs.u8.1 Pressure test of blanchability pulmw tissues oo What is Hemochromatosis ? (iron overload or "bronze" diabetes)? -Hemochromatosis is a disease that causes the body to store excessive amounts of iron (normal amount=5gm). To It is an inherited disorder that can lead to the onset of type 1 diabetes after years of iron overload (can damage the pancreas). Healthy people usually absorb about 10 % of the iron contained in their food, to meet the body needs. Pts. with hemochromatosis absorb more than the body needs, to be stored in body tissues, especially the liver, heart, and pancreas. Hala H Hazzaa  The classic manifestations include: 1) Diabetes mellitus. 2) Liver cirrhosis.00 3) Skin pigmentation. 4) Sometimes, heart failure. o The oral mucosal lesions are T.EE brown to gray diffuse macules that tend to occur in the palate and gingiva. - Skin pigmentation is attributed to: increased iron conc. in circulation & deposition in skin. increased melanin production 2ry to adrenal dysfunction. irontmelanin Hala H Hazzaa  Hemochromatosis is often called “bronze” diabetes because of an accompanying skin discoloration. Hala H Hazzaa Qualitative changes Discoloration RBCs destruction in hemoglobin due to RBCs To 1. Reduced hemoglobin: RBCs destruction (cyanosis bluish & hemoglobin breakdown, discoloration of skin & e.g. oral mucosa), 2ry to I Petechiae, heart and lung disease. Ecchymosis 2. Carboxyhaemoglobin: jaundice. II (cherry red color), due to carbon monoxide Holmolysis inhalation. I II ONO III T.IS Hala H Hazzaa  e vBlue, red ∕ Purple Vascular Lesions: 1. Hemangioma 2. Varix 3. HHT 4. Kaposi’s Sarcoma Hala H Hazzaa  Hemangioma Clinically: - It is as a benign proliferation of the endothelial cells that line the vascular channels. TIIt - Onset: in 85% it appears early in childhood. - Color intensity depends on the depth of vascular tissue: reddish blue, deep blue or even with no color. toe 80% of hemangiomas spontaneously regress after puberty -Clinical appearance: It is either flat macule or nodular. ü ü It blanches on pressure (Diascopy??). varix jls -Treatment: Ge wj cryosurgery, surgical laser (Argon-laser) intra lesion injection using Sclerosing agents (1% sodium tetracycline sulfate) T.FI N.B: It results in postoperative pain & the patient must use analgesic Hala H Hazzaa Hemangioma is most common to appear on tongue & lips. It usually has a nodular surface & a blue/purple color. Hala H Hazzaa A) Glass slide for diascopy; endothelial B) Double slide test; C) Anatomy of a vascular lesion in cells 1 diagram; D) Clinical picture of a vascular lesion on lower lip; E) Application of pressure with a glass slide results in peripheral pooling of blood; Diascopy test positive in vascular lesion in lower lip. 11  3H Varix Clinically: -It is a focal dilatation of a vein or a group of venules. Cip BuccalmucosaT -What are the most common INTRA-ORAL sites?? -It becomes progressively prominent with age...Why? -Clinical appearance: may be blue, red or purple with nodular surface. -Differential diagnosis: hemangioma. How to differentiate? onset + etiology. Hala H Hazzaa  Etiology The reason for venous distention is unclear but it may be related to weakening of the vessel wall / deformed valve secondary to aging.  Intraoral: it may be seen on the ventral surface of tongue the chief site of involvement followed by the lower lip and cheek mucosa. Hala H Hazzaa  Hereditary Hemorrhagic Telangiectasia (Rendu-Osler-Weber syndrome) -Rare genetic condition characterized by multiple mucocutaneous lesions (red to purple) macules, nodules and telangiectases, that develop from dilated capillaries. -It occurs due to endothelial discontinuity caused by: 1. Degeneration or defective overlapping at endothelial junction, 2. Lack of elastin 3. Inadequate smooth muscle in perivascular CT Oral manifestations: Multiple round purple papules < 0.5cm in diameter On lips, tongue and buccal mucosa. Hala H Hazzaa Telangiectasia: or spider veins are small dilated blood vessels near the surface of the skin or mucous membranes, measuring (0.5-1) mm in diameter. v Abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as lungs, liver, & brain. Gastro-intestinal bleeding Epistaxis No treatment for the disease. If the patient would like the removal of the lesion areas for cosmetic reasons, cauterization is indicated by electro-cautery procedures using local anesthesia. It is prominent in adults DD: Petechial hemorrhages, due to trauma or platelet disorder !!! (How can you differentiate?). Hala H Hazzaa  herpesvirusetype.to gig Kaposi’s Sarcoma: (Due to HHV8) Clinically: severconditiontimmunity -It’s a tumor of vascular origin (cells that line LNs or BVs) & doesn’t show a great tendency of metastasis. -Mostly, it occurs parallel with HIV (Diagnostic sign). -Most common site: posterior palate. gingiva a om rc ) sa ate ) i’s al iva os (p n g p ly gi Ka Mai ite ( n nd s 1. 2 Hala H Hazzaa 2. Roo perforation of blood Vessels Clinical appearance: -Kaposi sarcoma appears as flat red macule of variable size & irregular configuration. -The early flat lesion is painless large & irregular that may interfere with mastication. -Treatment: 1. 2. Is Anti-viral combination chemotherapy, cryotherapy, radiotherapy. Electro-surgery or intra-lesional injection by sclerosing agent. Hala H Hazzaa vGray ∕ Black Pigmentations: 1. Amalgam Tattoo 2. Graphite Tattoo 3. Hairy Tongue 4. Pigmentation Related to Heavy-Metal Ingestion Hala H Hazzaa -Heavy Bjj elements which metals: are trace metallic have a high atomic weight and a density much greater (at least 5 times) than water. -There are more than 20 heavy metals; -Four of them are of particular concern to human health Lead Mercury (Pb) (Hg) Inorganic I Cadmium (Cd) Arsenic (As). II How????? Hala H Hazzaa -They are taken into the body via: -Inhalation, ingestion & skin absorption. -If heavy metals enter and accumulate in body tissues faster than the body’s detoxification pathways, a gradual buildup of these toxins will occur. MDI MPG w -Metallic intoxication may show marked systemic features affecting GIT, urinary bladder, CNC, skin…... l How????? Hala H Hazzaa  Enumeration A 0 Nate necrotizing ulcer w.tw Oral manifestations gingivitis 1. Metallic taste. 2. Metallic line affecting salivary glands & marginal consecrators gingiva. co 3. Enlarged salivary glands, with increased secretion. 4. Itching sensation. sometimes Xerostomia 5. Sore & inflammed tongue. 6. Tongue tremors (plumbism & mercurialism). no 7. susceptibility to ANUG. Not 8. Regional lymph node enlargement. 9. Alveolar bone destruction. 10. Lip cracking, dryness, swelling (mercurialism). lymphadenopathy What????? Hala H Hazzaa  E Lead intoxication "Plumbism“ due to; Contamination, occupational (Industries) e The previously listed oral manifestations. go.mg dI Peripheral neuritis wrist and foot drop. GIT: nausea, loss of appetite, Blood cells abdominal colic, constipation. w What????? jiff Plumbism interferes with bone turnover in children lead line in skull most important radiograph. Hala H Hazzaa  M Silver intoxication “Argyria“ due to; Continued local application, therapeutic Cyanotic discoloration of oral mucosa. Remember that: Cyanosis may be also related to cardiac or pulmonary disease. ecdyascopy Differential Diagnosis: Cyanosis due to argyria doesn’t blanch on pressure. Blood cells Generalized fwjtheqrdic.rumonaryJeases Cyanosis What????? Hala H Hazzaa  2 1 Arsenic intoxication is due to; Therapeutic, occupational Pigmentation and dry mouth. Arsenic dressing in RCT if comes in contact with oral tissues, it causes ulceration or pass beyond apex leading to periodontitis & osteomyelitis. Keratosis of palms & soles and skin pigmentation Gastroenteritis armouth Blood cells mass Aplastic anemia depression to bone Agranulocytosis What????? wbscol.by Hala H Hazzaa  D Mercury “Mercurialism” due to; Drug overdose, occupational, suicidal attempts add The previously listed oral manifestations. To CNS disturbance: Insomnia, tremor, fever & headache. GIT: colis, diarrhea, vomiting. Blood cells What????? Hala H Hazzaa o Mercury intoxication in children is called “acrodynia” CNS disturbance: Insomnia, tremor, Exfoliation of deciduous teeth, atrophy of alveolar bone, necrosis of oral tissues and excessive salivation. fever & headache. Redness, swelling, itching & desquamation of palms and soles Blood cells What????? Hala H Hazzaa  Bismuth Gold  Causes  Causes Therapeutic use Therapeutic use (e.g. in rheumatoid arthritis)  Systemic manifestations  Systemic manifestations GIT disturbance, peripheral neuropathy, fever, jaundice. Platelets & WBCs deficiency. Renko thrompoasto.pe a  Oral manifestations  Oral manifestations Listed before. Ulcerative stomatitis. Hala H Hazzaa  weds.TL I1 gingival margin In case of gingival Metal salts circulate in inflammation, capillary blood till reaching the permeability is increased gingival capillaries. leading to metal passage to C.T. This deposition will: Metals will react with 1. Interference with hydrogen sulphide forming gingival nutrition. insoluble ppt of metal 2. Lower its resistance. sulphide (metal line). 3. susceptibility to ANUG. WT fetal breath Hala H Hazzaa The diagnosis of this condition is based on: metalic IS calculus III line Clinical Case history (occupational or examination: therapeutic exposure) 1. Metallic line. 2. Paper corner test. I 7 Clinical features; It affects mainly the free gingival margin Hala H Hazzaa 1) Good oral hygiene. 2) Management of secondary lesion. 3) Vit. C; as a prophylactic in lead factories + atropine to control salivation. 4) 30% H O2 WHY? To oxidize the insoluble metal sulpfide Soluble metal sulphate. Hala H Hazzaa Hala H Hazzaa  Metallic (lead) line intoxication Hala H Hazzaa 1. The most common source of solitary (focal) pigmentation in the oral mucosa. 2. The lesions are focal bluish gray or even black macules, usually seen in the buccal mucosa, gingiva, or palate. 3. Diagnisis: they are found close to teeth with large amalgam restorations. Hala H Hazzaa  g gva al GbswS Graphite Tattoo 1. It tends to occur on the palate, representing traumatic implantation from a lead pencil. 2. The lesions are, focal, gray or black macules. 3. History is important for diagnosis. Hala H Hazzaa record Black hairy tongue is an oral condition which is short-term and harmless. It is caused by too much bacteria or yeast growth in the mouth which make the tong ue a p p ea r b la ck a n d ha ir y. I t i s a l s o recognized as “Hairy tongue”. Black hairy tongue generally resolves without medical treatment. Hala H Hazzaa  Wd filliform papillae 011 The surface of tongue has tiny rounded projections known as papillae. The papillae begin to develop and lengthen, creating hair like projections in place of shedding. They can develop to 15 times their normal length. Thepapillae are pinkish-white but pigments from food, drinks and possibly the bacteria or yeast themselves get caught in the papillae, dyeing the tongue, as they grow. Most frequently that color is black, but the tongue can also turn brown, yellow, green, or a variety of other colors. Hala H Hazzaa Causes of Black Hairy Tongue 1. Poor oral hygiene 2. Dehydrated. 3. Certain antibiotics. 4. Drinking a lot of coffee or tea. 5. Radiation therapy to the head and neck. 6. Smoking tobacco. 7. Taking medications that contain bismuth. 8. Regular use of mouthwashes that contain peroxide or menthol. Hala H Hazzaa Symptoms: 1. Black, yellow or brown discoloration of the tongue. 2. Altered taste or metallic taste in mouth. 3. Bad breath. 4. Gagging sensation in some people. 5. A hairy or furry appearance of the tongue. Hala H Hazzaa  Hairy tongue Hala H Hazzaa  Brushing Tongue scraper Hala H Hazzaa THANKS FOR LISTENING