PIGMENTED LESIONS 2
DR.S.KARTHIGA KANNAN
PROFESSOR
ORAL MEDICINE & RADIOLOGY
SPECIFIC LEARNING OBJECTIVES
 TO KNOW ABOUT HEMOGLOBIN DERIVED ENDOGENOUS PIGMENTATION
AND EXOGENOUS PIGMENTATION.
 TO RECOGNISE THE CLINICAL FEATURES OF HEMOGLOBIN DERIVED AND
EXOGENOUS PIGMENTATION.
 TO KNOW THE INVESTIGATION AND MANAGEMENT OF THESE LESIONS
FORMAT
1. CLASSIFICATION OF HEMOGLOBIN DERIVED ENDOGENOUS PIGMENTATION
2. CLINICAL FEATURES OF HEMOGLOBIN DERIVED PIGMENTATION
3. CLASSIFICATION OF EXOGENOUS PIGMENTATION
4. CLINICAL FEATURES OF EXOGENOUS PIGMENTATION
Blue purple red - Hemoglobin derived vascular lesions
Hemangioma
 Pyogenic granuloma
 Varix
 Angiosarcoma
 Kaposi sarcoma
 Hereditary hemorrhagic telengectasia
HEMANGIOMA
a. Etiology – Developemental / hamartomas
b. Age - commonly in childhood
c. Clinical Types:
 Cavernous
 Capillary
d. Appearance - superficial lesion as reddish
blue and deep lesion as blue in color.
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e. Associated with sturge weber syndrome, port wine stain… etc
f. Investigations
 Radiography, Angiography, MRI.
g. Treatment
 Intra lesional injection of 1% sodium tetradecyl sulphate, sodium morrhuate
and sodium psylliate.
 Lasers
 Cryosurgery
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PYOGENIC GRANULOMA
Etiology.
Pyogenic granuloma represents an exuberant
connective tissue proliferation to a known
stimulus or injury.
It appears as a red mass because it is
composed
predominantly
of
hyperplastic
granulation tissue with prominent capillaries.
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Clinical Features.
It occur mostly in the second decade of life
Most commonly seen on the attached gingiva (75%),
 They are caused by the presence of calculus or foreign material within the gingival
crevice
Treatment.
surgical excision; as well as removal of local etiologic factors (plaque, calculus, foreign
material, source of trauma). Recurrence is occasional and is believed to result from
incomplete excision, failure to remove etiologic factors, or reinjury of the area.
VARIX
 Etiopathogenesis :Pathologic dilatations
of veins or venules due to degenerative
changes in adventitia of venous walls.
Clinical features:
a. Common in old age
b. Appear as tortuous, serpentine, blue/ red/
purple elevations.
c. Painless and are not subjected to rupture or
hemorrhage
d. Can be seen on lips, buccal mucosa &
ventral surface of tongue
e. Management : if symptamatic injection of
sclerosing agents
Varix in floor of
Oral cavity
DIASCOPY
In this procedure a glass slide is placed over a suspected vascular lesion and pressure
is applied, the lesion shows decrease in size (compressibility) and color becomes pale
( blanching).
KAPOSI’S SARCOMA
 Moritz Kaposi described this indolent
malignant tumor of vascular origin with slow
progressive growth.
 Two types are:
1.Endemic form prevalent in africa
2.Epidemic form associated with HIV/AIDS
 Clinical features
 Seen as red/blue/ purple lesions on hard palate
or facial gingiva. In late stages it turns into brown
color
 The discoloration is seen because of extravasation of erythrocytes & deposition of
hemosiderin.
 Lesions are painless, unsightly & may interfere in mastication sometimes.
 Treatment: Cryosurgery, Sclerosing agents, biweekly multiple Intralesional 1%
vinblastine sulphate injections
HEREDITARY HEMORRHAGIC TELEGIECTASIA
 Genetically transmitted hereditary disease
 Characterized by round/oval purple colored
papules measuring 0.5cm in 100s of numbers on
lips, facial skin, neck, nasal mucosa etc.
Lesions represent multiple micro aneurysms
due to weakening defect in adventitious coat of
venules.
 More common in adults
 History of epistaxis
 No treatment required. For cosmetic purposes cryosurgery can be done
BROWN BLACK - HEAMOSIDERIN PIGMENTATION
RBC in tissue 
Lysis of RBC 
Hb liberated 
taken up by macrophage – stored as hemosiderin
TYPES
 Purpura
PURPURA – It is a clinical sign characterized
 Petechiae
 Ecchymosis
 Hematoma
by extravasation of blood into the connective
tissue of skin /mucosa and bleeding from
body orifices.
PETECHIAE
 They are often associated with systemic
blood disorders like leukemia,
thrombocytopenic purpura etc and can
also be seen in infection like infectious
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mononucleosis, violent coughing etc .
 Lesions appear red,blue, purple, or
black in color
 Size – 1-2 mm
 Do not blanch in diascopy due to the
presence of extravasated blood in the
tissues.
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ECCHYMOSIS
 Purpuric spots of more than 1 cm is
called as ecchymosis
HEMATOMA
 Localized
accummulation of blood in
the tissue is called Hematoma.
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YELLOW – BILIRUBIN DERIVED PIGMENTATION
A normal non-iron containing pigment in bile.
Normal level of bilirubin in blood is 1mg/dl.
Excess of bilirubin causes jaundice
Skin and sclera become yellow
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Gray Black Brown - Exogenous pigmentation
Types
Amalgam tattoo
Gray Black
iatrogenic trauma
Graphite tattoo
Gray black
trauma
Lead,bismuth,mercury
Gray,blue black
ingestion,inhalation, medicinals
Chromogenic bacteria
black,brown,green
superficial colonization
Metallic Intoxication
Definition:
It is introduction of heavy metals into the body almost at toxic level or
dose during occupational exposure or therapeutic administration or by
any other route of administration.
Types Of Heavy Metals:
1. Lead
2. Bismuth
3. Mercury
4. Silver
5. Gold
6. Copper
7. Arsenic
8. Zinc
General Oral Manifestations:
1. Metallic line on marginal gingiva & interdental papilla.
2. Metallic taste as metal circulates in blood then reaches salivary glands
then becomes secreted in saliva.
3. Enlargement of salivary glands.
4. Excessive salivary secretions.
5. Burning or itching sensation of oral mucosa due to irritation of
nerve endings.
6.Tongue may be swollen causing indentation markings
7. Increased susceptibility to necrotizing ulcerative gingivitis (NUG).
8. Regional lymphadenopathy which may be due to NUG.
Lead Intoxication (Plumbism)
- Source of lead :
1. Workers in battery stores or industry (mostly young aged persons)
2. Children toys
3. Water pipes made of lead
- Systemic
features:
1. Gastrointestinal upset as nausea colic or loss of appetite
2. Wrist drop or Foot drop due to peripheral neuritis of nerve supply
to extensor muscles.( very characteristic of lead intoxication)
- Laboratory
findings:
1. Basophilic stippling of R.B.C’S( very characteristic of lead intoxication)
2. Secondary anemia due to fragility of R.B.C’S
How To Diagnose & Differentiate
Metallic Line:(D.D)
Metallic line should be differentiated
from sub gingival stains or calculus:
By corner paper test :
 The corner of a white paper is inserted
In the gingival crevice or in
Corner paper test in lead line
the periodontal pocket.
If corner is accentuated hence metallic line
If disappears hence sub gingival stain calculus or amalgam filling
Dental Management Of Metallic Line:
1. Vitamin C administration to decrease capillary permeability.
2. Gingival or periodontal Treatment and establishing good oral hygiene
3. Treatment of acute necrotizing ulcerative gingivitis.
4. Repeated local application of 30% H2O2 (insoluble metal sulfide will
be changed into soluble metal sulfate)
5. Avoid smoking and spicy food to decrease burning sensation in oral
cavity.
6. Administration of 50 mg atropine tab. before meals or antihistamines
to decrease excessive salivation
AMALGAM TATTOO
¨ History of amalgam filling
¨ No gingival inflammation is noticed
¨ Not extending as metallic line
Adjacent to a filled tooth
Soft tissue radiography to evaluate
BLACK HAIRY TONGUE
ETIOLOGY AND PATHOGENESIS
 Elongation
of
the
filiform
papillae
produces a hair-like appearance on the
dorsum of the tongue.
The cause of the subsequent black
pigmentation
is
unknown,
although
chromogenic bacteria have been implicated.
 A range of predisposing factors have been
suggested, including smoking, antibiotic use
and iron treatment.
Management: Eliminate the cause and
encourage brushing of tongue to facilitate
desquamation on elongated filifiorm papilla.
FACE IS THE INDEX OF MIND
MOUTH IS THE MIRROR OF THE BODY; IT REFLECTS
SYASTEMIC DISEASES – SIR WILLIAM OSLER