Pigmented Lesions of Oral Mucosa

Introduction

• Overview of pigmented lesions of the oral mucosa

Causes of Oral Purpura/Petechiae

• Some significant causes include:
  • Amyloidosis
  • Aplastic anemia
  • Bulimia
  • Chronic renal failure
  • Fellatio
  • Forceful coughing
  • Hemophilia
  • Henoch-Schönlein purpura
  • HIV/AIDS
  • Infectious mononucleosis
  • Leukemia
  • Liver cirrhosis
  • Nonspecific trauma
  • Oral intubation
  • Oral submucous fibrosis
  • Overexertion
  • Papular-purpuric 'gloves and socks' syndrome
  • Streptococcal infection
  • Systemic lupus erythematosus
  • Thrombocytopenia
  • Von Willebrand's disease

Diseases Associated with Café Au Lait Pigmentation

• Commonly associated conditions include:
  • Ataxia-telangiectasia
  • Familial café au lait spots
  • Familial cavernous malformation
  • Fanconi's anemia
  • Hereditary nonpolyposis colorectal cancer
  • Idiopathic epilepsy
  • Johanson-Blizzard syndrome
  • McCune-Albright syndrome
  • Microcephalic osteodysplastic primordial dwarfism
  • Neurofibromatosis types 1 and 2
  • Nijmegen breakage syndrome
  • Noonan's syndrome
  • Ring chromosome syndromes
  • Russell-Silver syndrome
  • Tuberous sclerosis
  • Turcot's syndrome

Miscellaneous Lesions Associated with Oral Mucosal Discoloration

• Types of lesions and their colors:
  • Pyogenic granuloma: Red, blue
  • Peripheral ossifying fibroma: Red, blue
  • Peripheral giant cell granuloma: Red, blue
  • Mucocele: Blue
  • Mucoepidermoid carcinoma: Blue
  • Acinic cell carcinoma: Blue, purple
  • Lymphoma: Blue
  • Vascular leiomyoma: Red, blue
  • Metastatic cancer: Red, blue
  • Fordyce granule: Yellow
  • Lipoma: Yellow
  • Granular cell tumor: Yellow

Sources of Exogenous Oral and Perioral Pigmentation

• Iatrogenic Sources: Medications, trauma, treatment procedures
• Environmental Factors: Heavy metals, tribal customs, poor hygiene
• Specific Examples: Amalgam tattoo, chrysiasis, black tongue

Classification of Pigmented Lesions

1. Endogenous Pigmentation
   • Normal racial variation, disease-related pigments (e.g., Addison's disease)
2. Exogenous Pigmentation
   • Results from systemic introduction of pigments like bismuth, lead, silver, and mercury

Blue/Purple Vascular Lesions

• Hemangiomas
  • Common in children; most spontaneously regress by puberty
  • Found in various body parts including mucous membranes
  • Characteristics depend on vascular depth:
    • Reddish blue if superficial
    • Deep blue if deeper
• Sturge-Weber Syndrome
  • Encephalotrigeminal angiomatosis; associated with port-wine stain and seizures

Treatment of Vascular Lesions

• Observation: Commonly withheld as many hemangiomas regress
• Interventional Treatments: Intralesional sclerosing agents or surgeries for larger lesions

Kaposi's Sarcoma

• First described in 1872; associated with HIV and the human herpes virus 8
• Four major clinical presentations; oral lesions common with AIDS-related forms

Hereditary Hemorrhagic Telangiectasia (HHT)

• Features include:
  • Recurrent epistaxis
  • Telangiectasia presentation
  • Genetic basis with known loci

Brown Melanotic Lesions

• Sources include endogenous melanin, physiologic pigmentation, and drug-induced factors
• Melanin Production Mechanism:
  • Involves the enzyme tyrosinase converting tyrosine to melanin
  • Superficial vs. Deep Location: Determines the color appearance (brown vs. black/blue)

Oral Melanotic Macules

• A focal increase in melanin deposition; often common in lower lip due to sun exposure
• Asymptomatic, varying sizes, usually situated on gingiva
• Differential Diagnosis: Nevi, amalgam tattoos, melanoma

Diagnosis & Treatment Approaches

• Diagnosis: Clinical evaluation; excisional biopsy if malignancy suspected
• Medication Induced Pigmentation: Drug classes include antimalarials, minocycline, and contraceptives which lead to hyperpigmentation

Smokers' Melanosis

• Associated with tobacco use as a defensive mechanism; mostly reversible after cessation

Café Au-Lait Macules in Neurofibromatosis

• Characterized by irregular patches; six or more suggestive of neurofibromatosis
• Treatment often not necessary unless for cosmetic reasons

Endocrinopathic Pigmentation

• Examples:
  • Addison's Disease: Diffuse pigmentation mainly prior to trauma or folds
  • Cushing’s Syndrome: Characterized by facial edema and brown discoloration in the mouth

Malignant Melanoma

• Rare in the oral cavity; common in older adults in the facial region
• Exhibits specific growth phases (radial/vertical) which affect prognosis
• Distinguishing features:
  • Asymmetry, irregular borders, color variation, diameter, elevation

Diagnosis of Dental Stains

• Extrinsic Stains: Caused by plaque, tartar, foods, and habits (e.g. tobacco)

• Intrinsic Stains: Associated with restorative materials and trauma

• Common Extrinsic Stains Sources: Iron, tannins, tobacco, medications

Clinical Management of Discoloration

• Professional Cleaning: Removal of extrinsic stains
• Internal Treatments: Addressing intrinsic staining depending on cause