Pigmented lesions

Question 1

Physiologic pigmentation clinical features

Answer 1

symmetric, persistent pigmentation that does not alter tissue architecture such as gingival stippling that may not correspond to skin pigmentation. Some cases of Lichen Planus can show up as hyperpigmentation.

Question 2

Physiologic pigmentation Histopahtology

Answer 2

It is due to increased melanin production of normal number of melanocytes.

Question 3

Physiologic Pigmentation Differential

Answer 3

Smoking associated melanosis
Peutz-Jeghers syndrome
Addison’s disease
Melanoma

Question 4

Physiologic Pigmentation treatment

Answer 4

usually clinically diagnostic, however biopsy may be indicated if clinical features are atypical

Question 5

Smoking-Associated Melanosis Etiology

Answer 5

Components of tobacco smoke can stimulate melanocytes
Birth Control makes this more common
Anterior Labial Gingiva is most typically affected. Palate and buccal mucosa is associated with pipe smoking.

Question 6

Smoking-Associated Melanosis Histopathology

Answer 6

Melanocytes show increased melanin production, similar to physiologic pigmentation.

Question 7

Smoking-Associated Melanosis Differential

Answer 7

Physiologic Pigmentation
Diffuse melanoacanthoma
Peutx-Jegners syndrome
Addison’s Disease
Other systemic drugs
Melanoma

Question 8

Smoking-Associated Melanosis Treatment

Answer 8

smoking cessation causes improvement over months to a few years
If surface irregularity noted biopsy should be performed.

Question 9

Oral Melanotic Macule Clinical features

Answer 9

A focal pigmented lesion that may represent an intraoral freckle, post inflammatory pigmentation, or macules assocaited with peutz-Jeghers syndrome, Bandler Syndrome, or Addison’s Disease
predominantly from the vermilion of the lips and gingiva.
If they are seen in excess and have a peri-oral disctibution then Peutz-Jeghers syndrome or Addison’s disease shoudl be considered.

Question 10

Oral Melanotic Macule Histopathology

Answer 10

Melanin accumulation in basal keratinocytes and a normal number of melanocytes.
Typically melanophagocytosis is seen (melanin in connective tissue macrophages)

Question 11

Oral Melanotic Macule differential/treatment

Answer 11

early superficial melanoma
Blue Nevi
Amalgam Tattoo
If numerous
Peutz-Jeghers syndrome
Addison’s disease
Carney’s Complex
Bandler syndrome
Laugier-Hunziker Syndrome
Biopsy may be required to establish a definitive diagnosis

Question 12

Melanocytic Nevus Etiology

Answer 12

collections of nevus cells that are round or polygonal and typically seen in a nested pattern. They are found in epithelium or connective tissue, or both.
They are relatively rare lesions that may occur at any age, most commonly on the palate.

Question 13

Melanocytic Nevus Histopathology

Answer 13

THere are many types depending on where the cells are located, either at the junctional nevus, both CT and epithelium, only in connective tissue, or oval cells in the connective tissue.
malignant transformation is highly improbable.

Question 14

Melanocytic Nevus Differential

Answer 14

Melanotic Macule
Amalgam Tattoo
Melanoma
Hematoma, Kaposi’s sarcoma
Varix
Hemantioma

Question 15

Melanocytic Nevus Treatment

Answer 15

All suspected oral bevi should be excised
Excisional biopsy is usually indicated as they are typically less than 1cm

Question 16

Melanoma Etiology

Answer 16

Pre-existing melanosis was sometimes found to occur prior to melanoma.
2 biologic subtypes have been identified, invasive melanoma, and in situ melanoma. Invasive shows limited lateral spread with vertical growth, and in situ shows a junctional growth phase that may last months to years before entering a vertical growth phase. A third category of atypical melanosis includes cases with unusual number of melanocytes with abnormal morphology.
Strong predilection for the palate and gingiva, where more than 70% are found.

Question 17

Melanoma differential diagnosis

Answer 17

melanocytic nevus
Amalgam tattoo
physiologic pigmentation
melanotic macule
kaposi’s sarcoma

Question 18

Melanoma treatment

Answer 18

Surgery is the primary mode of treatment, and chemotherapy is often used. Treatment failures are most commonly assocaited with incomplete excision.

Question 19

Amalgam Tattoo Etiology

Answer 19

iatrogenic lesion following soft tissue implantation of amalgam particles, or passive transfer by chronic friction of mucosa against an amalgam restoration
The most commonly affected sites are adjacent to the teeth, including gingiva, buccal mucosa, palate, and tongue.
Lesions are macular and gray, and do not change appreciably over time. If the particles are large enough they can be seen on soft tissue radiographs

Question 20

Amalgam Tattoo Histopathology

Answer 20

The silver in amalgam stains collagen, imparting them iwht a black or golden brown colour. Lymphocyts and parmophages can be seen around large particles. Multinucleated foreign body giant cells can be seen containing amalgam particles.

Question 21

Amalgam Tattoo Differential

Answer 21

in gingival or palatal area, differentiation from a nevi and early melanoma is important, and can bd differentiated by radiographs, but questionable lesions should undergo biopsy

Question 22

Heavy-Metal Pigmentations Etiology

Answer 22

arsenic, bismuth, Platinum, Lead, and mercury can lead to oral pigmentation. This usually occurs after occupational exposure to vapors
Colour is grey/black and distribution is linear along the gingival margin

Question 23

Heavy-Metal Pigmentation significance

Answer 23

the underlying cause may be significant. This can occur in a dental office if chronic levels of mercury are present.