ORAL PIGMENTATION

Question 1

What is Black Hairy Tongue

Answer 1

• Elongation of filiform papillae
• Due to extrinsic staining
• e.g. xs smoking, chx, poor OH, wine, broad spectrum antibiotics
• overgrowth of pigment producing bacteria/fungi
• areas of white tongue are possible
• low fibre and dehydration

Question 2

Black hairy tongue management

Answer 2

• Reassure patient and inform them about BHT
• OHI
• Diet high in fibre and hydration
• Smoking VBA/drinking
• Avoid XS tongue brushing as this can exacerbate it
• Oxidising mouthwash (Peroxyl)

Question 3

What is Amalgam tattoo

Answer 3

• common in mandibular gingiva and alveolar mucosa
• May be due to XLA of tooth or removal of restoration made of amalgam
• Oral pigmentation of slate grey/blue black macule
• No elevation
• No change in size but margins will blur

Question 4

What is a Graphite tattoo

Answer 4

• Common in the palate of children
• second most common cause of exogenous localised oral pigmentation
• Biopsy to eliminate malignancy

Question 5

Mangement of amalgam/graphite tattoo

Answer 5

• Radiograph would show amalgam in tissue, depending on the density of surrounding bone and KV exposure/voltage
• Biopsy to eliminate malignancy
• Reassure patient
• Can be removed with Q-switch ruby laser (shatters tattoo and particles removed by lymphatics)

Question 6

Metal salt deposition

Answer 6

• Metal sulphides along the gingival margin
• Bismuth, lead, mercury
• present in crevicular fluid and precipitate as sulphides by hydrogen sulfide by plaque microorganisms
• Linear grey/black lines along gingiva as lead/burtons lines
• can be confused as subgingival calculus

Question 7

Ethnobotanical tattoo

Answer 7

• common in africa
• females as a rite of passage
• Thought to improve OH and eliminate bad breath
• tattoo of gingiva with soot covered thorns
• thought to be used as a remedy for dental pain

Question 8

Oral melanotic macule

Answer 8

• Benign localised area of increased melanin
• effects any mucosal surface but skin is more common
• common in F
• Lesion on lip due to sun damage
• Homogenous flat brown/black regular border
• <5mm

Question 9

Management of a oral malenotic macule

Answer 9

• Biopsy to eliminate malignancy and avoid long term follow up
• Lip lesions could be monitored if not suspicious

Question 10

Oral melanoma

Answer 10

• rare
• palate is most common but can effect anywhere (lip/gingiva)
• brown/black but 30% as amelanotic
• irregular border and colour (non-homogeneous)
• can be nodular (alarm bells for malignancy)

Question 11

Differential diagnosis for oral melanoma

Answer 11

• oral melanotic macule
• amalgam tattoo
• graphite tattoo - palate is common here

Question 12

Oral melanoma prognosis + metastasis

Answer 12

• oral melanoma has a poor prognosis 5-20% 5year survival

- metastasis to lymph, lungs, liver (3Ls)

Question 13

Ecchymosis aetiology

Answer 13

• blue/black/purple bruising due to:
  1) trauma e.g. fracture mandible
  2) underlying palatal/coagulation disorder

Question 14

Varcies

Answer 14

• Lower lip/sublingual
• vein dilation
• blue & lobulated
• blanch on pressure
• may have hard areas due to thrombosis/ clacified phleboliths forming

Question 15

Localised oral pigmentation

Answer 15

black hair tongue
amalgam/graphite tattoo
metalic salts
alcohol eg. red wine
tobacco/betel use
melanotic macules
malignant melanoma
kaposi sarcoma

Question 16

Generalised oral pigmentation causes

Answer 16

DEVELOPMENTAL

• racial pigmentation
• peutz-jeghers
• pigmented naevi

MEDICATION e.g. tetracylines/chloroquine

HABITS

• smoking
• betel use

POST-INFLAMMATORY

ASSOCIATED W SYSTEMIC DISEASE

• endocrine eg. addisons disease (blue/black), cushings disease
• metabolic
• infective

Question 17

What is Peutz Jeghers syndrome

Answer 17

• autosomal dominant condition
• Mutation in LKB1 or ch19 which codes for serine-threonine-kinase (plays a role in apoptosis)
• multiple perioral/vermillion border freckles/melanotic macules
• pigmented spots intraorally, extremities, nasal and rectal mucosa
• melanotic macules are not malignant
• Haematomatous intestinal polyps + abnominal and rectal bleeding
• risk of internal malignancy
• monitor this!

Question 18

What does betel nut cause

Answer 18

• TSL as its abrasive
• oral submucous fibrosis
• lichenoid reaction (mucositis)
• epithelial dysplasia
• increase risk of malignancies/OSCC
• leukoplakia
• staining (buccal+teeth)

Question 19

Manage betel/paan use

Answer 19

• VBA betel nut cessation
• Nicotine replacement patches
• biosy to eliminate malignancy

Question 20

Drug-induced hyperpigmentation (BLUE/GREY VS BROWN)

Answer 20

BLUE GREY:

• fluoxetine
• chloroquine
• minocycline/tetracycline
• amiodarone

BROWN

• minocycline/doxycycline/tetracycline
• propanolol
• busulphan

OTHERS
arsenic+sulphydryl groups =melanin deposit
phenothiazine+minocycline react w melanin

Question 21

ADDISONS DISEASE

Answer 21

• insufficiency / atrophy of adrenal cortex
• increased ACTH= increased MSH= increase melanin
• BLUE BLACK ORAL PIGMENTATION
• pigmentation/bronzing on cutaneous sun exposed areas
• genital pigmentation
• side effect of systemic corticosteroids

Question 22

Addison disease management

Answer 22

life long steroid hormone replacement therapy (HRT)

Question 23

Cushings disease

Answer 23

• xs cortisol hormone
• oral pigmentation blue/black
• side effect of systemic corticosteroids