Pigmented Lesions Flashcards
what are the benign melanocytic lesions
- physiologic
- smoker’s melanosis
- traumatic melanosis
- ephelis
- lentigo
- oral melanotic macule
what are the neoplastic pigmented lesion
- nevi
- melanoma
- neuroectodermal tumor of infancy
what are the exogenous pigmented lesion
- metal pigment
- amalgam tattoo
- drug induced pigment
what is the endocrine pigmented lesion
addison disease
what is the genetic pigmented lesion
peutz jehger syndrome
what is the etiology of physiologic pigmentation disorders
normal melanocyte activity
what is the clinical presentation of physiologic pigmentation disorders
- seen in all ages
- symmetric distribution over many sites gingiva most commonly
- surface architecture, texture unchanged
what is the dx of physiologic pigmentation disorders
- history
- distribution
what is the DDX of physiologic pigmentation disorders
- mucosal melanotic macule
- smoking associated melanosis
- superficial malignant melanoma
what is the tx of physiologic pigmentation disorders
none
what is the prognosis of physiologic pigmentation disorders
excellent
what is the etiology for traumatic melanosis
- a reactive and reversible alteration of oral mucosal and melanocytes and keratinocytes
- usually associated with local trauma
what is the clinical presentation of traumatic melanosis
- unilateral dark plaque, rarely multiple, bilateral
- most often noted among blocks and other non caucasians
- occurs more often in women than men by a ratio of 3:1
- history of trauma and local irritation
- forms rapidly most often on buccal/labial mucosa
- asymptomatic melanotic pigmentation
what is the dx for traumatic melanosis
- clinical history of rapid onset
- histologic evaluation
- scattered dendritic melanocytes within spongiotic and acanthotic epithelium
- increased number of melanocytes along basal layer as single units
what is the DDX for traumatic melanosis
- melanoma
- drug induced pigmentation
- smokers melanosis
- mucosal melanotic macule
- mucosal nevus
- amalgam tattoo
what is the tx for traumatic melanosis
- none after establishing the dx
- often resolves spontaneously
what is the prognosis for traumatic melanosis
excellent
what is the etiology of smokers melanosis
- melanin pigmentation of oral mucosa in heavy smokers
- may occur in up to 1 of 5 smokers, especially females taking birth control pills or hormone replacement
- melanocytes stimulated by a component in tobacco smoke
what is the clinical presentation of smokers melanosis
- brownish discoloration of alveolar and attached labial gingiva, buccal mucosa
- pigmentation is diffuse and uniformly distributed; symmetric gingival pigmentation occurs most often
- degree of pigmentation is positively influenced by female hormones (birth control pills, hormone replacement therapy)
what are the microscopic findings in smokers melanosis
- increased melanin in basal cell layer
- increased melanin production by normal numbers of melanocytes
- melanin incontinence
what is the dx for smokers melanosis
- history of chronic, heavy smoking
- biopsy
- clinical appearance
what is the DDX for smokers melanosis
- physiologic pigmentation
- addisons disease
- medication related pigmentation
- malignant melanoma
what medications would cause smokers melanosis
- chloroquine
- clofazimine
- mepacrine
- chlorpromazine
- quinidine
- zidovudine
what is the treatment for smokers melanosis
- non
- reversible if smoking is discontinued
what is the prognosis for smokers melanosis
- good with smoking cessatoin
what is the etiology for mucosal melanotic macule and ephelides
- most idiopathic, some post inflammatory some drug induced
what do multiple lesions of mucosal melanotic macule and ephelides suggest syndrome wise
- peutz jeghers
- laugier hunziker
- carneys syndrome
- leopard syndrome
what is the clinical presentation of mucosal melanotic macule and ephelides
- most in adulthood - 4th decade and up
- most are solitary and well circumscribed
- lower lip vermillion border most common site mostly in young women ( labial melanotic macule)
- brown mucosa, palate, and attached gingiva also involved- mucosal melanotic macule
- usually brown, uniformly pigmented, round to ovoid shape with slightly irregular border
- usually less than 5mm in diameter
what is the etiology of a nevus
unknown but are benign tumors of melanocytes
what is the clinical presentation of a nevus
- usually elevated, symmetric papule
- pigmentation usually uniformly distributed
- common on skin; unusual intraorally
- palate and gingiva most often involved
what is the dx for a nevus
- clinical features
- biopsy
what is the DDX for a nevus
- melanoma
- hemangioma
- amalgam tattoo/foreign body
- mucosal melanotic macule
- Kaposi’s sarcoma
- ecchymosis
- melanocanthoma
what is the tx for a nevus
- excision of all pigmented oral lesions to rule out malignant melanoma is advised
- malignant transformation of oral nevi probably does not occur
what is the prognosis for a nevus
excellent
what are the variants of a nevus
- blue nevus
- compound
- amelanotic
- junctional
what is the etiology of a malignant melanoma
- unknown
- cutaneous malignant melanoma with relation to sun exposure or familial dysplastic melanocytic lesions
what is the etiology of mucosal malignant melanoma
- unknown and unlike the cutaneous malignant melanoma with relation to sun exposure or familial dysplastic melanocytic lesions
what is the clinical presentation of mucosal malignant melanoma
- rare in oral cavity (less than 1% of all melanomas) and sinonasal tract
- generally greater than 30 years of age
- usually arises on maxillary gingiva and hard palate
- may exhibit early in situ phase: a macular, pigmented patch with irregular borders
- progression to deeply pigmented, nodular quality with ulceration
- may arise de novo as a pigmented or amelanotic nodule
- rarely may be metastatic to the oral cavity as a nodular, usually pigmented mass
describe the mucosal spread of mucosal malignant melanoma
- early stage: atypical melanocytes at epithelial-connective tissue interface, occasionally with intraepithelial spread
- later infiltration into lamina propria and muscle
- strict correlation to cutaneous malignant melanoma is not well established, as in skin, a similar horizontal or in situ growth phase often precedes the vertical invasive phase
- a horizontal or in situ growth phase often precedes the vertical invasive phase
- initially a macular pigmented. patch with irregular borders
- progresses to deeply pigmented, nodular quality with ulceration
what stain is used for amelanotic forms of mucosal malignant melanoma
immunohistolchemical identifications such as S-100 protein, HMB-45, and Melan-A expression
what is the tx for mucosal malignant melanoma
- surgical excision
- marginal parameters related to depth of invasion and presence of lateral growth
- wide surgical margins; resection (including maxillectomy) for large, deeper lesions
- neck dissection in cases of deep invasion (less than 1.25mm)
what is the prognosis for mucosal malignant melanoma
- generally poor for most oral malignant melanomas
- less than 20% survival at 5 years in most studies
what is the etiology of amalgam tattoo
implantation of passtive/frictional transfer of dental silver amalgam into mucosa
what is the clinical presentation of an amalgam tattoo
- gray to black focal macules, usually well defined but may be diffuse with no associated signs of inflammation
- typically in attached gingiva, alveolar mucosa, buccal mucosa
- occasionally may be visible radiographically
- intact mucosa overlying black spot
- benign or malignant melanin pigmentation is usually brownish and occurs within the epithelium on the surfacr
what is the dx for amalgam tattoo
- radiographs
- biopsy may be necessary if clinical dx is in doubt or to rule out lesions of melanocytic origin
what is the ddx for amalgam tattoo
- vascular malformation
- mucosal nevus
- melanoma
- mucosal melanotic macule
- melanocanthoma
what is the tx for amalgam tattoo
biopsy or observation
what is the prognosis for amalgam tattoo
little clinical significance if untreated
what is Niksat
- a cultural tattoo
- age-old practice of body art in Ethiopia
- drawn on faces, necks, gums, and hands of young girls
- popular in older population
- darker gums is a criterion of beauty in rural areas of ethiopia
- drink a local liquir called Areki for conscious sedation
what is Niksat for
- beautification
- identity indicator
- ward off evil eyes
- curing enlarged thyroid glands on the neck
- gingival tattoos give healing powers for dental problems
Niksat on men’s gingiva is referred to as:
guramayle
what is the etiology of extrinsic drug or metal induced mucosal pigmentation
- occupational exposure- metal vapors ( lead, mercury)
- therapeutic - metal salts deposits (bismuth, cis platinum, silver, gold) also nonmetal agents such as chloroquine, minocycline, zidovudine, chlorpromazine, phenolphthalein, clofazimine, and others
what is the clinical presentation for extrinsic drug related or metal induced mucosal pigmentation
- focal to diffuse areas of pigmentary change
- if heavy metal are the cause, a typical gray to black color is seen along the gingival margin or areas of inflammation
- palatal changes characteristic with antimalarial drugs and minocycline
- most medications cause color alteration of buccal labial mucosa and attached gingiva
- darkened alveolar bone with minocycline therapy (10% at 1 year, 20% at 4 years)
what is the dx of extrinsic drug induced or metal induced mucosal pigmentation
- history of exposure to or ingestion of heavy metals of drugs
- differentiation from melanocyte-related pigmentation by biopsy if needed
what is the ddx of extrinsic drug induced or metal induced mucosal pigmentation
- when localized: amalgam tatoo, mucosal melanotic macule, melanocanthoma, mucosal nevus, ephelides, Kaposi’s sarcoma, purpura, malignant melanoma, ecchymosis
- when generalized: ethnic pigmentation, Addison’s disease
- if asymmetric: in situ melanoma must be ruled out by biopsy
what is the tx of extrinsic drug induced or metal induced mucosal pigmentation
investigation of cause and elimination if posible
what is the prognosis of extrinsic drug induced or metal induced mucosal pigmentation
excellent
what is argyria
Ag salts have antibacterial and anti neoplastic benefits
- bluish discoloration from therapeutic ingestion or industrial accident
what is the etiology of drug induced pigmentation disorders
- therapeutic drug related tissue pigmentation
- many drugs cause change
what is the clinical presenation of drug induced pigmentation disorders
- macular mucosal discoloration ( brown, gray,black)
- palate and gingiva are most common sites affected
- in addition to mucosal changes, teeth in adults and children may be bluish gray owing to minocycline/tetracycline use
what are the drugs capable of producing tissue pigmentation
- antimalarials: chloroquine, mepacrine, quinidine, old time antimalarials
- antibiotics: tetracycline group, minocycline
- antivirals: azidothymidine
- phenothiazine: chlopromazine, clofazimine
- heavy metals: gold, mercury salts, silver nitrate, bismuth, lead
- hormones: ACTH, oral contraceptives
- cancer/chemotherapy drugs: busulfan, cyclophosphamide, cis-platinum
- other: methyldopa
what is the etiology for tetracycline staining
- prolonged ingestion of tetracycline or its congeners during tooth development
- less commonly, tetracycline ingestion causes staining after tooth formation is complete: reparative (secondary) dentin cementum may be stained
what is the clinical presentation of tetracycline staining
- yellowish to gray (oxidized tetracycline) color of enamel and dentin
- may be generalized or horizontally banded depending on duration of tetracycline exposure
- alveolar bone may also be stained bluish red (particularly with minocycline use, 10% after 1 year and 20% after 4 years of therapy)
what is the dx for tetracycline staining
clinical appearance and histroy
- fluorescence of teeth may be noted with ultraviolet illumination
what is the ddx for tetracycline staining
dentinogenesis imperfecta
what is the tx for tetracycline staining
restorative/cosmetic dental techniques
what is the prognosis for tetracycline staining
good
what is addisons disease
destruction of adrenal cortex
- lowered cortisol and increased ACTH
- cannot tolerate stress: adrenal crisis
what is the etiology of addisons disease
- most commonly autoimmune
- chornic infectious disease and sepsis: HIV, CMV, fungal infection
- drugs
what does addisons disease require fot tx
- cortisol replacement
- surgery and stress may require supplemental corticosteroids
- pain control is important
what are the cutaneous findings in addison disease
-hyperpigmentation of skin and mucous membranes
- longitudinal pigmented bands in the nails
- vitiligo
- decreased axillary and pubic hair in women
- cailcification of auricular cartilage in men
what are the related features of addison disease
-abdominal pain
- electrolyte abnormalities - hyponatremia and hyperkalemia
- postural hypotension
- anorexia and weight loss
- fatigue
- shock, coma and death if untreated
how is addison disease dx
- failure to respond adequately to corticotropin stimulation test
what is the mangement for addison disease
lifelong replacement therapy of glucocorticoids and mineralocorticoids
what is secondary adrenal insufficiency and how is it treated
- impaired/destructive pituitary disease
- low cortisol and low ACTH; aldosterone unchanged
- lower dose replacement therapy
what is tertiary adrenal insufficiency and what is the treatment
- impaired function of hypothalamus
- most commonly a result of chronic exogenous steroid use
- lower dose replacement therapy
what needs to be considered with hyperadrenalism
- BP and glucose levels
- avoid NSAIDs and aspirin -> peptic ulcers, GI bleed
- if osteoporosis and osteopenia
- more prone to periodontal bone loss
- may have history of bisphosphonate use
- impaired wound healing may be a result of both hyperadrenalism and adrenal insufficiency
what does the neccesity for supplemental corticosteroids in adrenal insufficiency depend on
- type
- severity/stability/ medical status
- dental proceudre being performed (long: more than 1 hour or invasive)/ type of stress/dental infection
what are the signs of adrenal crisis
- hypotension - monitor BP- vasopressors, patient position, fluid replacement
- abdominal pain
- myalgia
- fever
- supplement with 100mg of hydrocortisone and send to ED
what needs to be considered with pain control with adrenal insufficiency
- adequate anesthesia, long acting agent at end of procedure
- good post op pain control
what is peutz jeghers and when do symptoms appear
- an autosomal dominant genetic condition affecting around 1 in 50,000 and 1 in 200.000 individuals
- symptoms usually appear during the first decade of life
what is seen in peutz jeghers
- dark skin freckling (melanocytic macules) around the mouth, eyes, nostrils, fingers, oral mucosa and perianal
- GI polyps (hamartomatous polyposis) causing nausea, vomiting, abdominal pain, intestinal obstruction and rectal bleeding
- increased risk for intestinal and other GI cancers
describe the mucocutaneous pigmentation seen in peutz jeghers
- seen in 95% of patients
- 1mm to 5mm in size
- appears by 1 or 2 years of age. fades after puberty except buccal mucosa
