Dania Session 4 Color Changes Pigmentedl

8/13/2019 Dania Session 4 Color Changes Pigmentedl

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MUCOSAL SURFACE LESIONSRegezi, et al. Oral Pathology

Melanocytic

Lesions

Non Melanocytic

Lesions

1. Physiologic (ethnic) pigmentation

2. Smoking associated melanosis

3. Oral melanotic macule

4. Caf-au-Lait macule5. Pigmented Neuroectodermal tumor

of infancy

6. Nevomelanocytic Nevus

7. Melanoma

1. Amalgam tatto (Focal

argyrosis)

2. Drug-induce pigmentation

3. Heavy-metal

pigmentation

Red-blue

Lesions

Pigmented

Lesions

Vesiculo-bulous

Diseases

Ulcerative

Condition

White

Lesions

Verrucal-PapillaryLesions

2


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DIFFERENTIAL DIAGNOSIS OF ORAL SOFT TISSUE SURFACE DISEASENikolaos G Nikitalis

COLOR CHANGES ORAL MUCOSAL LESION

Nikolaos G Nikitalis

WHITE

LESION

RED

LESION

PETECHIAL

AND

ECCHYMO

TIC LESION

1

WHITE AND

RED

LESION

YELLOW

LESION

FOCALDIFFUSE

ANDMULTIFOCAL

PIGMEN

TED

LESION

Exogenous stain Vascular lesion

Melanocytic origins

Salivary gland

origin

Cysts

Local factor

Exogenous stain

Vascular lesion

Melanocytic origins

Systemic diseases

Local factor


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A systematic approach to the assessment of a suspicious

oral mucosal lesion

1.

History of current illness :

onset, location, intensity, frequency, duration

aggravating and/or relieving variables

better, unchanged or worse over time

2.

Medical, tobacco and alcohol history:

medical conditions

medications and allergies

tobacco and alcohol (type, frequency, duration)

3.

Clinical examination

extra oral examination

intraoral examination

lesion inspection (adjunctive visual tools such as toluidine blue and

direct fluorescence)

4. Differential diagnosis

5. Diagnostic tests : biopsy

6. Definitive diagnosis

7. Suggested management


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Pigmented Lesion

The pigmented color of a lesion is usually

indicative of

1. The various conditions that cause focal or diffuse

pigmentation of the oral mucosa are classified on the basis

of their etiology or origin.2. The lesions may assume a multitude of various colors,

generally distinguished into predominantly blue/purple,

mainly brown/ gray/black.

3. Blue/purple discoloration of oral mucosa is produced byblood-containing vascular lesions, mucus-containing

salivary gland lesions, or fluid containing cysts.


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Pigmented lesions

4. In contrast, a brown/gray/black discoloration usually

ensues from accumulation of either exogenous stain or

melanin.

5. Amalgam tattoo represents on of the most common

focal pigmentations of the oral cavity.

6. Heavy metal ingestion, which often produces a linear

pigmented pattern along the free gingival margin, due tooccupation .


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Melanocytic lesions

1. Melanin producing cells (melanocyt) migrate toepithelial surfaces and reside among basal cells.

2. The processes of dendritic extend to adjacent

keratinocytes

3. Organelles packeged granules of pigment known asmelanosomes are produced by melanocytes.

4. Melanocytes are found throughout the oral mucosa but

unnoticed because of their relatively low level of

pigment production,

5. Oral melanin pigmentation range from brown to black to

blue, depending on the amount of melanin produced

and the depth of the pigment relative to the surface


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Melanocyt-keratinocyte unit. Dendritic processes of

melanocyte and melanin transfer to keratinocytes.


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Physiologic (Ethnic) pigmentation

Clinical features

Physiologic pigmentation is simmetry and persistent

and does not altered normal structure.

Found in any location but the gingiva is the mostcommonly affected intraoral tissue.

Post inflamatory pigmentation accossionally seen

after mucosa reaction to injury.

The pigmentation is not to increase numbers ofmelanocytes but to increase melanin production.


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Smoking-associated Melanosis

Ethiology and pathogenesis Abnormal pigmentation has been linked to cigarette

smoking and has been designated as smokers

melanosis

The component of tobacco smoke stimulatesmelanocyte.

Women who are those taking birth control pills are more

commonly affected than men.

Clinical features The anterior labial gingiva is the region most typically

affected.

Palate and buccal mucosa has been associated with

pipe smoking.


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Smoker's Melanosis


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Smoking-associated Melanosis

Clinical features The use of smokeles tobacco has not been linked to oral

melanosis.

In smoking associated melanosis the intensity of

pigmentation is time and dose related. Melanocytes show increase melanin production as

evidenced by pigmentation of adjacent basal

keratinocyte.

Differensial diagnosis Peutz-Jeghers syndrome, Addisons diseases and

melanoma

No treatment is necessary


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Oral Melanotic Macula

Clinical features Oral melanotic macule or focal melanosis is a focal

pigmented lesion that may represent of

o Intra oral freckle

o Post inflammatory pigmentationo The macules associated with Peutz-Jeghers syndr or

Addisons disease

Melanotic macules have been describe as occurring

predominatly on the vermilion of the lips and gingiva,

Asymptomatic and have no malignant potential.


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Oral Melanotic Macula

Clinical features

When melanotic macules are seen in excessive, Peutz-Jegher syndrome and Addisons disease should be

considered.

Peutz-J syn : epelides or melanotic macula, intestinal

polyposis, hamartoma Addisons disease: adrenocortical insufficiency, as a

result of autoimmune disease or idiopathic and then

MSH and ACTH increase

This increase then stimulate melanocyte leading todiffuse pigmentation.

Other presenting signs and symptoms of this syndrome

include weakness, weight loss, nausea vomiting and

hypotention.


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Oral Melanotic

Macule


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Caf au Lait Macula

Clinical features

Caf au Lait macula is a pigmented patches of skin,irregular margin and brown coloration.

It noted at birth or soon thereafter and may also be seen

in normal children.

No treatment required

If more than 1.5 cm it suspected to neurofibromatosis

(NF).

Neurofibromatosis 1 (NF1) : van Recklinghausens

disease and Neurofibromatosis 2 (NF2): acousticneurofibromatosis.


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Caf au Lait Macula

Clinical features The condition characterized by numerus neurofibromas

of the skin, oral mucosa, nerves, central nervous system

and jaw

The NF2 characterized : bilateral acoustic neuromas,and Lish nodules.

Caf au Lait may also be associated with Albrights

syndrome (polyostotic fibrous dysplasia, endocrine

dysfuvctgion, precurious puberty, macula No treatment is required


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Nevomelanocytic nevus

Etiology

Nevus is a general term that may refer to any congenitallesion of various cell or tissue type

It is sometimes called more specifically,

neuromelanocytic nevus, nevocelllular nevus,

melanocytic nevus or pigmented nevus. This nevus are collection of nevus cells that are round or

polygonal and are typically seen in a nested pattern.

Clinical features

The lesion usually appear on the skin shortly after birth

Palate is the most commonly affected site.

Less common site is gingiva, alveolar ridge and

vermillion.


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Congenital HairyNevi


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Histopathology

There are several subtype. Classification is dependent

on the location of nevus cells.

When cells are located in

o the epithelium-connective tissue junction, the lesion is called a

junctional nevus.

o In connective tissue, the lesion called intradermal nevus

o In a combination of zones, the lesion is called compound nevus.

o Deep in the connective tissue is known as blue nevus.

Because oral nevomelanocytic nevi can mimicmelanoma clinically, all undiagnosed pigmented lesion

should undergo a biopsy


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The Blue Nevusor Malignant Melanoma


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Differential diagnosis

Melanotic macula

Amalgam tattoo

Melanoma

Hematoma

Kaposis sarcoma

Varix

Treatment Because of their ability to clinically

mimic melanoma, all suspected oral

nevi should be excised


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Peutz-Jeghers Syndrome


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Addison's Disease


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Generalized Pigmentation Due To

Addison Disease


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Melanoma

Cutaneus melanoma

Is more common in location - closer

to the equator.

More in white than Black

Several subtype :

o nodular melanoma,

o superficial spreading melanoma,

o acral lentiginous melanoma,o lentigo maligna melanoma.

Oral melanoma


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Melanoma

Oral melanoma

Oral melanoma is rare

No rasial predilection; but Asians appear to be

proportionately more commonly affected

There are 3 subtype: invasive melanoma, insitumelanoma and atypical melanocytic proliferation

Atypical melanocytic proliferationhigh risk lesion

Palate and gingiva have predilection

Pigmentation patern that suggest melanomainclude different mixtures of color such as brown,

black-blue and red asymmetry and irregular

margin.- ABCS


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Melanoma

Differential diagnosis

Nevus

Amalgam tattoo

Physiologicx pigmentation

Melanotic macule kaposi.s sarcoma

Treatment and Prognosis

Biopsysurgerychemotherapy

Supportive treatmentradiation

Prognosis depend on histologic and depth

invasion


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Oral malignan melanoma


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Oral malignan melanoma


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Non Melanotic Lesions

Amalgam Tattoo

Or focal argyrosis is an iatrogenic lesion that

follows traumatic soft tissue implantation of

amalgam particles

A passive transfer by chronic friction of mucosaagainst an amalgam restoration.

Follows teeth extraction, preparation having old

amalgam fillings for gold casting restoration or

polishing

Clinical features

The most affected site is the gingiva, bujccal

mucosa, palate and tongue.


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Amalgam tattoo


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Non Melanotic Lesions

Amalgam Tattoo

Histopathology

The amalgam particles have an affinity for

collagen fibers and elastic fibers of blood vessels The particles staning them a black or golden

brown color

Few lymphocytes and macrophages are found,

except in cases in which particles are relativelylarge.

Giant cells may also be seen


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Drug-InducedBlack Hairy Tongue


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C o n c e p t


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1. PIGMENTED LESIONS OF THE ORAL MUCOSA

Blue, brown and black discoloration constitute the

pigmented lesions of the oral mucosa,

these lesions represent a variety of clinical entities, ranging

from:-

a) physiological changes (e.g. racial pigmentation ).

b) manifestations of systemic illnesses (e.g. Addisonsdisease).

c) Malignant neoplasm (e.g. melanoma and Kaposi

sarcoma)

d) Exogenous pigmentation is commonly due to foreign-

bodyimplantation in the oral mucosa.

e) Endogenous pigments include melanin,

hemoglobin,hemosiderin and carotene


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Differential Diagnosis of Oral Pigmented

Lesion evaluation of the pigmented lesion should include:

a) Full medical and dental history :

o the history should include the onset and duration

o the presence of associated skin hyper pigmentation

o the presence of systemic signs and symptoms (e.gmalaise, fatigue, weight loss) and smoking habits.

b) Extra oral and intra oral examinations:

o pigmented lesions on the face, perioral skin and lip

o the number, distribution, size, shape and colour ofintraoral pigmented lesions should be assessed.


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Differential Diagnosis of Oral Pigmented

Lesion evaluation of the pigmented lesion should include :

c) Investigations such as diascopy test, radiography,

biopsy

d) laboratory investigations such as blood test can be

used to confirm a clinical impression and reach adefinitive diagnosis.


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3. Pigmented lesions are classified into:

Blue/Purple Vascular Lesions.

a) Hemangioma :Vascular lesions presenting as

proliferations of vascular channels are tumor like

hamartomasb) The lesion may harbor vessels close to the overlying

epithelium and appear reddish blue or, if a little

deeper in the connective tissue, a deep blue.


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3. Pigmented lesions are classified into:-

Blue/Purple Vascular Lesions.

c) Treatment :

o Conventional surgery, laser surgery, or cryosurgery.

o Larger lesions that extend into muscles are moredifficult to eradicate surgically, and scleroting agents

such as 1% tetradecyl sulfate may be treated by intra

lesional injection


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5. Varix (pathologic dilatations of veins or venules are varices or varicosities)

a) The chief site of such involvement in the oral tissues is the

ventral tongue

b) Clinicaly: Lingual varicosities appear as tortuous serpentine

blue, red, and purple elevations that course over theventrolateralsurface of the tongue, with extension

anteriorly.

c) They are painless and are not subject to rupture and

hemorrhage

d) Some can be blanched, others are not, due to the

formation of intravascularthrombi.


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7. Hereditary Hemorrhagic Telangiectasia

a) Characterized by multiple round or oval purple papules

measuring less than 0.5cm in diameter,

b) Hereditary hemorrhagic telangiectasia (HHT) is a

genetically transmitted disease, inherited as an autosomal

dominant trait

c) There may be more than100 such purple papules on the

vermilion and mucosalsurfaces of the lips as well as on

the tongue and buccal mucosa.

d) The facial skin and neck are also involved.


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7. Hereditary Hemorrhagic Telangiectasia

e) Examination of the nasal mucosa will reveal similar

lesions, and a past history of epistaxis may be a

complaint.

f) Deaths havebeen reported in HHT attributable to epistaxis

g) Differential diagnosis :

petechial hemorrhages with an attending plateletdisorder,

petechiae are macular rather than papular

Foci of erythrocyte extravasation (with breakdown tohemosiderin) red or brown rather than purple


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8. Microscopically:

a) HHT shows numerous dilated vascular channels with

some degree of erythrocyte extravasation around the

dilated vessels.

b) There is no treatment for the disease. If the patientwould like to have the telangiectatic areas removed

for cosmetic reasons, the papules can be cauterized

by electro cautery in a staged series of procedures

using local anesthesia


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Ephelis


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12. Treatment:

Excision with wide margins is the treatment of choice

This may be difficult to accomplished because of the

anatomical constrains and proximity to the viral

structures. radiation and chemotherapy are ineffective

The prognosis for patients with oral melanoma is worse

than that for patients with cutaneous lesions

The overall 5-years survival rate is 15%.

Dania Session 4 Color Changes Pigmentedl

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