Exogenous Pigmentation

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CONTENTS

                 

                       INTRODUCTION

     The systemic administration of various drugs and chemicals frequently evokes an oral and body reaction which is not on the basis of an allergy or sensitivity. The reaction is often a part of a generalized epidermal reaction, but other times it occurs as a specific phenomenon apparently due to the anatomical peculiarities of the oral cavity

DEFINITION

        Pigmentation which arises as a result of introduction of metals or drugs into the body via mucous membrane, intestinal tract and skin.

CLASSIFICATION

1.    ACCIDENTAL PIGMENTATIION   :   Accidental implantation of material in

                                                            the gingival tissue.

2.    IATROGENIC PIGMENTATION     :   Due to dental procedure

3.    HEAVY METAL PIGMENTATION  :   Due to ingestion of metals like bismuth,

                                                             lead , mercury in the body.

               ACCIDENTAL PIGMENTATION

            Foreign substances are embedded in the gingival tissue.

·      Accident during childhood : For example , if one falls on road, some particles of road surface get embedded in gingival and if not removed , may cause discolouration

·      Charcoal tooth powder  : Charcoal containing tooth powder also produces black pigment discolouration

·      Graphite tattoos : Pencil points are occasionally broken off in gingival tissue and if not completely removed , may cause permanent discolouration . The lesions are macular, focal & grey or black .

           IATROGENIC PIGMENTATION    

AMALGAM  TATTOO

      It is also called “Localized argyrosis”. Characterised by the deposition of restorative debris in subepithelial connective tissue

ETIOLOGY

1.    Restorative work                  :  It occurs during routine amalgam restoration

2.    Removal of old filling           :  It may enter the mucosa lacerated by rotary

                                                   instruments during removal of old  

                                                   amalgam fillings

3.    Extraction                              :  Broken pieces may be introduced into the              

                                                   socket or beneath the periosteum

4.    Retrograde amalgam filling  : Particles may enter the surgical cut during

                                                        RCT.

CLINICAL  FEATURES

·         Site                  :  Gingiva and alveolar mucosa

·         Age & sex       :  Females , rarely below twelve years

·         Appearance    :  Flat macule or slightly raised lesions with well defined margins

·         Color               :  Blue black in color

          

DIFFERENTIAL DIAGNOSIS

·         Superficial hemangioma

·         Nevus & melanoma

INVESTIGATION

·            Radiograph

·            Excisional biopsy

MANAGEMENT

·            Surgical excision

         HEAVY METAL PIGMENTATION

BISMUTHISM

        It is systemic metallic intoxication due to bismuth compound.

   ETIOLOGY

·         Medicinal use

·         Occupational exposure

   PATHOGENESIS

         Pigmentation is produced by the action of hydrogen sulphide on the bismuth compound.The hydrogen sulphide is formed through bacterial degradation of organic material of food retention

   CLINICAL FEATURES

·         Git disturbances

·         Nausea

·         Bloody diarrohea

·         Jaundice

·         Bismuth line  :  White bands of increased density appear in the ends   

                            of  the  diaphyses  immediately  adjacent  to  the   

                            epiphyseal lines in  long bones

  ORAL MANIFESTATIONS

·            Metallic taste

·            Burning sensations in the oral cavity

·            Ulcerative gingivostomatitis

·            Enlarged sore tongue

·            Shallow ulcerations seen on cheek mucosa in molar region

·            Bluish black bismuth line

     PAPER TEST  :  To know whether the pigmentation is actually in gingival

                                  tissue.

    MANAGEMENT

·            Removal of cause

·            Maintenance of oral hygiene

·            Topical anaesthetics- lignocaine hydrochloride gel

PLUMBISM

         It occur due to lead poisoning

   ETIOLOGY

•      Paint

•      Alcohol

•      Gasoline

•      Occupational exposure

•      Plumbing

•      Welding

•      Lead oxide batteries

    PATHOGENESIS

•         Absorption of lead from alimentary tract, gut and lungs

•         Modulated by vit D & ca status of the individual

•         Lead is taken up by circulating erythrocytes & bound to reactive sulfhydryl group of proteins

•         Lead is transferred to all soft tissue from circulation

•         In the red cells lead inhibits enzyme associated with Hb synthesis.hence abnormal activity of the enzymes occurs

 

CLINICAL FEATURES

1.    CNS :   Lead encephalopathy

                   Cerebral palsy

                   Mental retardation

                   Seizures

                   Foot or wrist drop

2.    GIT :    Nausea

            Constipation

            Vomiting.

3.   BONE : Interfere with cellular metabolism, change in rate of bone     

            resorption and apposition.

  ORAL MANIFESTATIONS

Ø  Metallic taste

Ø  Excessive salivation

Ø  Dysphagia

Ø  BURTONIAN LINE  : A gray black line along the gingival margin. Lead line

                                  is more diffuse than bismuth line.

Ø  Pallor of lip

Ø  Ashen face

Ø  Tremor of tongue on thrusting

Ø  Bilateral parotid gland hypertrophy.

  MANAGEMENT

            CHELATING AGENTS :  Lead can be removed from body by using chelating agents like EDTA, DMSA [2,3-dimercapto-succinic acid DMPS [2,3dimercaptopropane-1-sulfonate]

MERCURIALISM

          Also called Pink disease, Swift’s disease, Dermatopolyneuritis , Acrodynia

  ETIOLOGY

• Medicinal use
• Mercury in dental amalgam
• Mercury in paint
• Mercurial diuretics
• Night creams
• Occupational

             

CLINICAL FEATURES

  AGE :  Infants below the age of 2 years.

  GIT SYMPTOMS : Intestinal colic , diarrohea, dysphagia, pharyngitis, nausea, abdominal

                                   pain

  CNS SYMPTOMS : Headache, insomnia, tremors of finger & tongue, mental depression

  RENAL SYMPTOMS :  Severe intoxication cause death.

  RAW BEEF APPEARANCE: The skin of hands, feet, nose, ears and cheek becomes

                                                    clammy red or pink

  SKIN : Affected area peels off,  maculopapular rashes

 ORAL MANIFESTATIONS

Ø  Metallic taste

Ø  Ropy viscid saliva

Ø  Blue black gingiva

Ø  Ulcerative stomatitis

Ø  Swollen salivary glands

Ø  Enlarged tongue

Ø  Dry lips

Ø  Loosening of teeth

Ø  Bruxism

 RADIOLOGICAL FEATURES

      Irregular bone destruction with loss of cortex of the follicle of the affected    tooth.

MANAGEMENT

Ø  Bed rest and dietary regimen for renal damage

Ø  ATROPINE & BELLLADONA can be used for the control of salivary flow.

Ø  Chelating agents like BAL ,DMS & DMPS

SILVER POISONING ( ARGYRIA )

It is also called “argyrosis” which occurs due to chronic exposure to silver compound.

   ETIOLOGY

§   Medicinal use  : Silver used in nasal drops

                                   Silver arsphenamine injection used to treat syphilis.

§   Photographic films

§   Occupational exposure

  CLINICAL FEATURES

·         Site   :  Exposed body surfaces, nail beds

·         Skin   :  Slate gray , cyanotic or violet skin , metallic luster

·         Nails : Deeply pigmented

                    

ORAL MANIFESTATIONS

Ø  Diffuse pigmentation of gingival & mucosal tissue.

Ø  Slate blue silver line along  the gingival margin

Ø  Diffuse bluish black discoloration of oral mucosa

MANAGEMENT

   Source of contact should be eliminated

ARSENISM

        It occurs due to arsenic poisoning

 ETIOLOGY

·         Industrial exposure

·         Medicinal use – to treat asthma & psoriasis

CLINICAL FEATURES

·         Chronic gastritis

·         Keratosis of palms of hand & soles of feet

·         Macular hyperpigmentation

·         Arsenical keratosis

COMPLICATIONS

·         Basal cell carcinoma

·         Squamous cell carcinoma   

                           

ORAL MANIFESTATIONS

·         Painful oral tissue

·         Excessive salivation

·         Severe gingivitis

·         Necrotizing ulcerative stomatitis

·         Hyperkeratosis of tongue

·         Deep red tissues

MANAGEMENT

·         Surface anaesthetic ointment such as  LIDOCAINE DICLONINE  solution used to control pain.

·         CHELATING AGENTS : BAL, DMPS, DMSA

GOLD POISONING

               It is also called auric stomatitis .

ETIOLOGY

       Medicinal use  : Gold is useful  for the treatment of rheumatoid arthritis,

                                 leprosy, lupus erythematosis

CLINICAL FEATURES

·         Dermatitis

·         Pruritis

·         Purpura

·         Alopecia

·         Loss of nails

·         Chrysiasis : Slate blue discoloration of skin 

ORAL MANIFESTATIONS

Ø  Site    : Buccal mucosa, lateral border of tongue palate, pharynx

Ø  Symptoms : Metallic taste, stomatitis ( most common),

Ø  Signs  :  Vesiculations & ulcerations of oral mucosa

MANAGEMENT

·         Patient advised to discontinue gold therapy

·         Alkaline mouth wash to treat stomatitis.

                        

OTHER PIGMENTATIONS

·         COPPER    :  Bluish green line of gingiva and teeth  called  “CLAPTON LINE”.

·         CHROMIUM : Dryness of mouth, painful ulcerations of nasal septum and  

                        teeth show persistent deep orange color.

·         ZINC  :  Bluish gray line on gingiva, painful submaxillary lymph nodes &  

              salivary gland

CONCLUSION

     It is clear that oral pigmentation is a relatively common condition that can occur in any portion of the oral cavity and arises from intrinsic and extrinsic factors . The dentist may be the first health care professional to observe the colour changes in the oral cavity which may be a manifestation of the underlying pathological process.

REFERENCE

1.   Burket ’s Oral medicine           : Greenberg , Glick , Ship

2.   Textbook of Oral medicine      :   Anil Govindrao Ghom