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