OMFPR 16 - Pigmented Lesions (Dr. Menon)

- Melanin

- Vascular structures

- Saliva/Mucin

- Cystic fluid

- Foregin material

What are the sources of pigment?

non-melanin

Are these Non-Melanin or Melanin-Associated pigmented lesions?

- Exogenous

- Endogenous

melanin-associated

Are these Non-Melanin or Melanin-Associated pigmented lesions?

- Developmental

- Reactive/Inflammatory

- Infectious

- Autoimmune and immune mediated

- Metabolic/Systemic

- Neoplastic

- Premalignant/malignant

exogenous (non-melanin)

What type of pigmented lesions are the following?

- Amalgam tattoo

- Graphite and other foreign body tattoos

- Medication-induced pigmentation

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoos

What are these metallic specs?

amalgam tattoos

These are clinical features of what?

- Asymptomatic, localized

- Blue-gray macule

- Localized around areas with amalgam restorations

gingiva/alveolar ridge mucosa (50%, then buccal mucosa, then floor of mouth)

What is the most common location of amalgam tattoos?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What type of pigmented lesion?

amalgam tattoo

What are the arrows pointing to?

amalgam in scar tissue

What are the black particles embedded in the purple?

amalgam in scar tissue

What are the black particles embedded in the purple?

amalgam tattoos

These are histopathologic features of what?

- Pigmented fragments

- Staining of reticulin fibers

- Large fragments surrounded by fibrosis

amalgam tattoo

What type of pigmented lesion?

graphite (or other foreign body tattoos)

What type of pigmented lesion?

graphite (or other foreign body tattoos)

What type of pigmented lesion?

foreign body tattoo

What type of pigmented lesion?

medication induced pigmentation

These are etiopathologies of what pigmented lesion?

- Accumulation of melanin

- Increase in melanin production

- Decrease in melanin clearance

- Accumulation of medication

- Synthesis of special pigments (I.e. Lipofuscin)

- Deposition of iron

medication-induced pigmentation

These are clinical features of what pigmented lesion?

- Diffuse, painless, symmetric bluish-gray macule

- Melanonychia and skin lesions

medication-induced pigmentation (typically palatal mucosa)

What type of pigmented lesion?

Minocycline

What medication has the following proposed source of pigmentation?

Hyperproduction of melanin, complex with iron,

or stained bone

- Antimalarials

- Hormones

What medications have the following proposed source of pigmentation?

Hyperproduction of melanin

Clofazamine

What medication has the following proposed source of pigmentation?

Chelated metabolites of medication

Tranquilizers

What medication has the following proposed source of pigmentation?

Medication/metabolites and/or accumulation of melanin

Heavy metals

What medication has the following proposed source of pigmentation?

Granules of the metal distributed throughout blood vessels

Amidorone

What medication has the following proposed source of pigmentation?

Increased production of lipofuscin

medication-induced (Imatinib-induced hyperpigmentation)

What type of pigmented lesion?

medication-induced (Imatinib-induced hyperpigmentation)

What type of pigmented lesion?

medication-induced (Imatinib-induced hyperpigmentation)

What type of pigmented lesion?

medication-induced

What type of pigmented lesion?

medication-induced

What type of pigmented lesion?

medication-induced

What type of pigmented lesion?

medication-induced

What type of pigmented lesion?

medication-induced

What type of pigmented lesion?

medication-induced

What type of pigmented lesion?

medication

Skin hyperpigmentation can be caused by what?

medication

Skin hyperpigmentation can be caused by what?

Amalgam tattoo

What type of pigmented lesion?

Amalgam tattoo

What type of pigmented lesion?

medication-induced

What type of pigmentation has lots of pigmentation in collagen fibers and has melanocytes in basal cells?

medication-induced

What type of pigmentation has lots of pigmentation in collagen fibers and has melanocytes in basal cells?

D. Corticosteroids (used to treat hyperpigmentation)

The most common medications to cause drug-induced gingival pigmentation include all except:

A. Minocycline

B. Chloroquine

C. Cyclophosphamide

D. Corticosteroids

E. Azidothymidine

Heavy metal

These types of metals can cause _________ toxicity

- Lead

- Mercury

- Silver

- Bismuth

- Gold

heavy metal toxicity

What can cause the following?

- Pigmentation of marginal gingiva

- Tongue tremor

- Metallic taste

- Excessive salivation

- Trichotillomania

- Bruxism

heavy metal toxicity (Burton line)

What type of pigmentation?

heavy metal toxicities

The burton line is a line that can show up along the gingival line that is associated with what ?

- Tea

- Coffee

- Tobacco

- Poor oral hygiene

- Dehydration

What can cause a coated tongue?

- Hemosiderin

- Bilirubin

What are two types of endogenous (non-melanin associated) pigmented lesions?

hemosiderin

What type of deposit is shown on this histology?

hemosiderin (giant cells)

What type of deposit is shown on this histology?

bilirubin

What type of deposit is shown on this histology?

neural crest cells

What cells do melanocytes develop from?

neural crest cells

What are pluripotent cells (melanocytes, neurons and glial cells, adrenal medulla, cardiac cells and craniofacial tissue)?

MITF

What gene is essential for lineage survival, proliferation or to prevent trans- differentiation towards other neural- crest lineages (such as glia and neurons)?

basal layer

Which layer of the epithelium are melanocytes housed in?

Yes

Do people of color have more oral mucosa pigmentation?

gingiva

Where is the most common location of melanin-associated pigmented lesions?

hard palate

Where is the second most common location of melanin-associated pigmented lesions?

buccal mucosa

Where is the third most common location of melanin-associated pigmented lesions?

Ephelides

What is the clinical term for freckles?

first decade

When do freckles typically appear?

female

Do ephelides (freckles) have male or female predilection?

ephelides (freckles)

These are clinical features of what?

- Sharply demarcated, uniformly light brown, round-to-oval macule (< 3mm)

- Sun-exposure

ephelides (freckles)

What type of pigmented lesion?

ephelides (freckles)

This is histology for what?

Melanocyte

What is the arrow pointing to?

basal layer

What layer are melanocytes in?

melanotic macule

What type of pigmented lesion?

melanotic macule

What type of pigmented lesion?

postinflammatory hypermelanosis

What type of pigmented lesion?

postinflammatory hypermelanosis (eg. smoker's melanosis)

What type of pigmented lesion?

melanocanthosis

What type of pigmented lesion?

5th decade

When do oral melanotic macules usually appear?

females (2-3:1)

Do oral melanotic macule have male or female predilection?

oral melanotic macule

These are characteristics of what pigmented lesion?

- Discrete, solitary (usually), tan to brown painless macule

- Most commonly found on lip mucosa then gingival/palatal mucosa, then buccal mucosa

- If multiple, explore...

oral melanotic macule

What type of pigmented lesion?

oral melanotic macule

What type of pigmented lesion?

oral melanotic macule

What type of pigmented lesion?

oral melanotic macule

What type of pigmented lesion?

oral melanotic macule (or amalgam tattoo?? Will need more context on exam!))

What type of pigmented lesion?

oral melanotic macule

What type of pigmented lesion?

oral melanotic macule

Which type of pigmented lesion has these histopathologic features?

- Increased level of melanin in basal and para-basal layers of epithelium and connective tissue

post-inflammatory hypermelanosis

What is a similar type of pigmented lesion to melanotic macules but have inflammation?

post inflammatory hyperpigmentation

What type of pigmented lesion?

smoker's melanosis

What type of pigmented lesion?

- Post-inflammatory hyperpigmentation

- Facial gingiva affected most often

- May be seen in 20% of smokers

smoker's melanosis

Patient is a smoker. What type of pigmented lesion?

oral melanoacanthosis (a.k.a. oral melanoacanthoma)

What type of pigmented lesion?

- Rare acquired pigmented lesion(s) of rapid onset

- Reactive?

- May reach several cm in size

African American females

Oral Melanoacanthosis has a predilection for which ethnic group and which gender?

3rd-4th decades

Oral Melanoacanthosis usually appears at which age?

oral melanoacanthosis

What is the differential diagnosis?

45 year-old African American female presented with this asymptomatic lesion for 2 months.

oral melanoacanthosis

What pigmented lesion has these histopathologic features?

- Dendritic melanocytes throughout epithelium

- Thickened epithelium

- Increase in basal layer melanocytes

- Spongiosis and mild acanthosis

- Biopsy to r/o melanoma

- No further rx required

What is the treatment of oral melanoacanthosis?