6. PHYSIOLOGICAL PIGMENTATION
Physiologic pigmentation is the most common source of multifocal or diffuse oral
Dark-complexioned individuals, including blacks, Asians, and south- Americans.
Mostly restricted to the gingiva, melanosis of other mucosal surfaces is not
The pigment is often observed in childhood and usually does not develop de novo
in the adult.
Differential Diagnosis; idiopathic, drug-induced, or smoking-induced melanosis.
If esthetics are disturbed, Gingivectomy and Laser therapy can be used to remove
8. EPHELIS AND ORAL
Skin vs. Oral Mucosa
Skin: Asymptomatic, small (1–3 mm), well-circumscribed, brown-colored macule
that is often seen on the sun-exposed regions of the facial and perioral skin.
Oral: Small (<1 cm), well-circumscribed, oval or irregular in outline and often
Light-skinned individuals and in red- or light blond–haired individuals.
No therapeutic intervention is required.
Biopsy after 2 weeks if persistent
DDx: Nevus, Amalgam Tattoo, Focal Ecchymosis and Melanoma
More in Females, over 30 years old
Hard Palate, the buccal and labial mucosae and gingiva
Asymptomatic, small (<1 cm), solitary, brown or blue, well-circumscribed nodule
Up to 15% of oral nevi may not exhibit any evidence of clinical pigmentation.
Biopsy is necessary for diagnostic confirmation.
Treatment: complete but conservative surgical excision
Highly malignant oral tumors.
Amelanotic melanomas can manifest as red lesions.
Isolated dark brown or black lesions that tend to occur on the palate, initially may
be symptomatic, nodular or macular lesion that is firm to palpate.
Male predilection, but it’s one of the most commonly occurring cancers in women of
The prognosis for oral melanoma is poor.
De Novo or from existing Nevus
15 – 40% 5 –year survival rate, if distant lymph nodes are involved then it drops to
less than 10%
18. DRUG-INDUCED MELANOSIS
10 – 20% of all cases
May remain after withdrawal of the medication
Antimalarials, Hydroxyquinolones, Quinolones, Gold, Oral Contraceptives
Large Diffuse pigmentation on the hard palate or diffuse multifocal
20. SMOKER’S MELANOSIS
Anterior maxillary and mandibular gingivae, buccal mucosa, lateral
tongue, palate, and floor of the mouth.
Most smokers (including heavy smokers) usually fail to show such
Brown, flat, and irregular; some are even geographic or map-like in
If there is a reduction in smoking, the pigmentation may eventually
Autosomal dominant disease.
Intestinal polyposis, cancer susceptibility, and multiple, small, pigmented
macules of the lips, perioral skin, hands, and feet measuring <0.5 cm in
Lips and perioral skin but may also develop on the anterior tongue and
buccal and labial mucosae.
25. CAFÉ AU- LAIT PIGMENTATIONS
Tan/ Brown – Coloured irregularly shaped macule
Neurofibromatosis type I; Neurofibromas with Multiple Café Au- Lait pigmentations
McCune-Albright syndrome; Polyostotic Fibrous Dysplasia, Café Au- Lait spots and
26. HIV/ AIDS ASSOCIATED MELANOSIS
Diffuse or multifocal mucocutaneous pigmentation has been frequently
described in HIV-seropositive patients
Could be due to antifungal and antiretroviral drugs or as a result of
CD4+ T-Lymphocytes count cells/µL less than or equals 200
May present with a history of progressive hyperpigmentation of the skin,
nails, and mucous membranes.
28. ECCHYMOSIS – PURPURA –
Ecchymosis; Bright red macule due to trauma, resolves by 2 weeks.
Capillary hemorrhage; Red initially then turns blue
Purpura; Multiple, small 2 to 4 mm collections of extravasated blood.
Petechiae; pinpoint or slightly larger than pinpoint collections of extravasated
Purpura and Petechiae on the soft palate can be due to viral infections or suction
Chronic, progressive disease, excessive iron deposition (usually in the form of
hemosiderin) in the liver and other organs and tissues.
Primary and Secondary (Excessive iron, anemia, liver cirrhosis)
The oral pigmentation is often diffuse and brown to gray in appearance.
Palate and Gingiva are most commonly affected.
Prussian blue stain will confirm the presence of iron
Skin, Scalp and Mucous Membranes
Color depends on depth
Tongue and Lip
Most resolve by the age of 10
Sturge- Webber Syndrome; Hemangioma, Seizures and Tram-line calcifications of
It treatment is needed: Conventional or Laser Surgery or Intralesional 3% Sodium
Sublingual area – Ventral tongue
Differences from Hemangioma
1. Old age
2. Doesn’t resolve spontaneously
35. KAPOSI’S SARCOMA
• Classic Kaposi’s sarcoma is seen on the oral mucosa and the skin of the
lower extremities in older men, or in the lymph nodes of children in
• HIV associated Kaposi’s Sarcoma is a diagnostic sign for AIDS, seen on
the palate+ and facial gingiva.
• The early plaque or macular lesions are painless and
require no therapy.
– Intralesional injections of sclerosing agent; painful
– Intralesional multiple biweekly injections of 1% vinblastine sulfate is
beneficial ( no significant postoperative pain).
37. HEREDITARY HEMORRHAGIC
Multiple round oval papules < 0.5 cm in diameter may be more than 100 in number
Nasal mucosa (epistaxis is common, fatal epistaxis has been reported), lips, tongue,
buccal mucosa, facial skin and neck.
Platelet studies can be ordered to rule out blood dyscrasia.
41. HAIRY TONGUE
Discoloration of the dorsal tongue, particularly the middle and posterior one-
The filiform papillae are elongated, sometimes markedly so, and have the
appearance of fine hairs.
Variant colours of chromogenic bacteria; white, green, brown, or black.
Treatments consist of having the patient brush the tongue, or use a tongue
scraper, and limit the ingestion of color-forming foods and drinks until the
43. HEAVY METAL INGESTION
• May be an occupational hazard
• Lead, mercury and bismuth.
• Seen along the free marginal gingiva (eyeliner- like)
• Associated with systemic symptoms: behavioral changes, neurologic
disorders, and intestinal pain.
• Rarely seen now