WELCOME

PIGMENTED LESIONS OF ORAL MUCOSA

Oral and Perioral pigmentation may be physiologic (or) pathologic in origin.

Assume variety of discolorations, including brown,blue, grey & black.

These color changes often occur due to deposition,production (or) increased accumulation of various endogenous (or) exogenous pigmented substances.

CLASSIFICATION ENDOGENOUS PIGMENTATION FOCAL MELANOCYTIC PIGMENTATION1. Freckle / Ephelis2. Oral / labial melanotic macule3. Oral melanoacanthoma4. Melanocytic nevus5. Malignant melanoma MULTIFOCAL / DIFFUSE PIGMENTATION1. Physiologic pigmentation2. Drug induced melanosis3. Smoker melanosis4. Post inflammatory hyper pigmentation5. Melasma (chlosma)

MELANOSIS ASSOCIATED WITH SYSTEMIC (OR)GENETIC DISEASE

1.Hypo adrenocorticism (addison’s disease)2.cushing’s syndrome3.Hyperthyrodism (graves disease)4.Primary biliary cirrhosis5.Vitamin b12 deficiency6.Peutz jeghers syndrome7.Café au lait pigmentation8.HIV / AIDS associated melanosis

IDIOPATHIC PIGMENTATION Laugier – hunziker pigmentationDEPIGMENTATION Vitiligo

HAEMOGLOBIN & IRON ASSOCIATED PIGMENTATION

a.Ecchymosisb.Purpura / Petechiaec.Hemochromatosis

EXOGENOUS PIGMENTATION

Focal melanocytic pigmentation

Freckle / ephelis :The cutaneous freckle is a commonly

occuring, asymptomatic , small (1 – 3mm), well circumsribed , tan or brown colored macule that is often seen on sun exposed regions of facial & perioral skin.

Polymorphisms in mc1r gene is strongly associated with development of childhood freckles.

Oral / labial melanotic maculeEtiology is traumaMore commopn in females usually in lower

lip &gingiva.May develop at any age but generally tend to

present in adulthood.Melanotic macules tend to be small (<1 cm),

well circumscribed , oval or irregular in outline & often uniformly pigmented.

Oral melanoacanthoma

Etiology is acute trauma or a history of chronic irritation

Rapidly enlarging , ill defined , darkly pigmented macular or plague like lesions.

Buccal mucosa most common site of occurrenceDermatosis papulosa nigra is relatively common

facial condition in older black females & represents multiple pigmented seborrheic keratoses

Treatment is source of irritation should be removed

Melanocytic nevusEffect of sun exposure reconized in development

of cutaneous nevi.Recent study shows 90% of dermal melanocytic

nevi exhibit somatic activating mutations in BRAF oncogene.

Lesions are usually asymtomatic & often present as a small (<1cm) , solitary , brown or blue , well circumscribed nodule or macule.

Oral nevi present in hard palate is the most common site , followed by buccal & labial mucosa & gingiva.

Treatment of melanotic nevi is complete but conservative surgical excision is the treatment of choice for oral lesions.

Rare recurrence

Laser & intense pulse light therapies have been used successfully

Malignant melanomaEtiology is episodes of acute sun exposure ,

especially at young age , immunosuppresionExhibit mutation in the BRAF , HRAS &

NRAS proto oncogenes.Palate represents most common site & next

comes the maxillary gingiva.They are macular , plague like or mass

forming , well circumscribed or irregular & exhibit focal or diffuse areas of brown , blue or black pigmentation.

Treatment is ablative surgery with wide margins .

Adjuvant radiotherapy is necessary.

Recent development is antitumor vaccine adjuvant interferon alpha – 2B therapy is used to treat primary cutaneous melanomas >4mm in thickness.

Multifocal / diffuse pigmentationPhysiologic pigmentation is more commonMostly occur in gingivaTreatment is gingivectomy & laser therapy

have been used to remove pigmenteds oral mucosa.

Effects of treatment is temporary & may eventually recur.

Drug induced melanosis

Chief drugs include a) Minocycline – tetracycline derivativeb) Antimalarials include chloroquine , hydroxy

chloroquine , quinacrine .c) Phenothiazines such as chlorpromaqzined) Oral contraceptivese) Cytotoxic medications such as

cyclophosphamide & busulfan

Clinically the pigment can be diffuse yet localised to one mucosal surface , often hard palate

Lesions are flat & without any evidence of nodularity or swelling.

Diagnosis & treatment is discolaration tends to fade within a few months after the drug is discontinued.