Diagnosis and Management of Physiologic and Pathological Oral Pigmentations

Introduction

Oral Pigmentations are common and are seen on gums, oral mucosa, and tongue. These pigmentations can be normal or abnormal. There are various types of oral pigmentation, and dentists differentiate between physiologic and pathologic pigmentation and suggest different treatment strategies available. The article discusses different types of oral pigmentation, differentiating physiologic and pathologic pigmentation, the significance of proper treatment, and the various treatment strategies.

What Are the Factors Affecting the Pigmentation of the Oral Cavity?

Pigmentation refers to the deposition of pigments in bodily tissues. The oral mucosal epithelium, which includes soft tissues in the mouth such as oral mucosal membranes and the tongue, may not always have a uniform color due to various levels of chromatic variation. This variation is particularly observed in certain physiologic or pathologic states.

Oral pigmentation, including that of the tongue, is primarily associated with endogenous (internal) or exogenous (external) factors.

• Endogenous Factors: Endogenous pigmentation is often caused by the presence of various pigments in the human body, including melanin, melanoid, oxyhemoglobin, reduced hemoglobin, and carotene. Endogenous pigmentation can also result from additional causes like bilirubin or iron deposition within the local oral tissues.

• Exogenous Factors: Exogenous pigmentation frequently occurs due to reactions to foreign bodies or the implantation of foreign materials within the oral mucosa. Pigmented lesions in the oral mucosa or on the tongue can range from blue, brown, to black discolorations.

What Are the Causes of Physiologic Pigmentation in the Oral Cavity?

The common causes of physiologic oral pigmentation include:

• Common Occurrence: Physiologic pigmentation is commonly seen in non-caucasian individuals, without any gender predilection.

• Age-Related Prevalence: The prevalence of physiologic pigmentation of the tongue is directly proportional to aging. These pigmented areas can vary in size and shape, ranging from light brown to black.

• Localized Tongue Pigmentation: Physiologic pigmentation of the tongue is often less frequent compared to other locations in the oral cavity. It affects the tips of the fungiform papillae or the lingual dorsum.

• Melanin Accumulation: The leading cause of physiologic pigmentation can be melanin accumulation, which increases melanocytic activity in specific tongue or oral cavity areas.

• Factors Influencing Progression: Individuals with existing hyperpigmented areas in the tongue or oral cavity may experience an accelerated progression due to factors such as tobacco exposure, smoking, hormonal fluctuations, or systemic medications or drug therapies.

• Common Sites: Besides the tongue, these pigmentations can also be commonly seen in the attached gingiva of teeth, appearing as well-demarcated brown or black bands. Physiologic pigmentations may occur in the buccal mucosa, lips, and palate.

Is It Possible for Pigmentation to Affect the Tongue?

The tongue is the largest organ within the oral cavity and comprises four types of papillae which include filiform, fungiform, foliate, and circumvallate papillae. The lingual papillae situated on the underside of the tongue serve to increase its surface area and have taste buds, for improved contact and friction during the processes of chewing and swallowing. Among these papillae, the fungiform papillae appear as club-shaped projections scattered on the tongue's tip and sides. In individuals with good oral health, papillae are typically seen as a pink to red hue, consistent with the surrounding oral mucosa. Some individuals exhibit pigmented fungiform papillae, which appear as discrete projections which is a common occurrence.

How Do One Differentiate Between Physiologic and Pathologic Pigmentations?

The process of distinguishing physiologic brownish pigmentations from pathologic ones in the oral cavity is based on the specific characteristics of the lesions. Pathologic pigmentation includes several conditions, such as melanotic macule, nevus, melanomas, ecchymosis, drug-induced lesions, and multifocal lesions associated with malignancies. Once a pathologic lesion is identified, it becomes imperative for dentists or surgeons to determine whether the pigmentations are benign or malignant (cancerous). This determination is made following a comprehensive assessment of the patient's medical history and overall systemic health status, where clinical findings play a crucial role in confirming whether the pigmentation is of a physiologic or pathological nature.

A detailed patient medical and dental history, combined with thorough extraoral and intraoral examinations conducted by the dentist, is needed to establish the nature of the pigmented lesion. In cases of pathologic pigmentation within the oral cavity, biopsy (a sample tissue is taken from the lesion and sent for examination by a medical pathologist) or laboratory investigations may be necessary to confirm whether the lesions consist of benign tissue or contain cancer cells. The medical history of a patient plays a vital role in diagnosis. Systemic conditions like Peutz-Jeghers syndrome (development of non-cancerous growth in the gastrointestinal tract), Addison's disease (a chronic condition where the adrenal gland does not produce hormones), or various endocrine disorders, hyperpigmentation within the oral cavity is a common finding, often seen on the lips or perioral areas.

How Are Pigmented Oral Lesions Effectively Managed by Oral Surgeons?

The steps in management of oral pigmentations include:

• Examination

  • Physiologic Pigmentation: The physiologic pigmentation, like endogenous pigmentation, may not require treatment unless it is for cosmetic reasons.

  • Medical and Dental History: The patient's medical and dental history is important for establishing the nature of the pigmented lesions.

• Treatment:

  • Cryotherapy: For recurrent pigmented lesions, whether benign or malignant, cryotherapy is a modern treatment choice. It involves freezing the lesion to cause local tissue destruction and reduce the chances of recurrence. Many oral surgeons prefer this method as it is less traumatic to surrounding tissue.

  • Biopsy and Histopathology: In cases where the nature of the lesion remains unclear or when malignancy is suspected, a biopsy is commonly performed. Pathologists then analyze the excised tissue to provide a definitive diagnosis and determine the appropriate treatment.

  • Laser Therapy: In superficial or precancerous lesions, oral surgeons may opt for laser therapy. Here the precise use of lasers to remove or treat the pigmented lesion while minimizing damage to surrounding tissues.

• Follow-up:

  • Regular Check Ups: After treatment, patients are typically placed on a long-term follow-up schedule to monitor for any signs of recurrence or new lesions. Regular check-ups are essential to ensure early detection and intervention if necessary.

  • Patient Education: Part of effective management involves educating patients about the nature of their pigmented lesions, treatment options, and the importance of regular oral hygiene and follow-up visits to maintain their oral health.

  • Multidisciplinary Approach: Oral surgeons often collaborate with other healthcare specialists such as oncologists, dermatologists, and pathologists to provide the most comprehensive care.

Conclusion

It is important to understand the significance of oral pigmented lesions to ensure they are properly assessed by a dentist and to distinguish between physiologic and pathologic cases. Timely diagnosis helps in early treatment and saves lives by addressing malignant conditions. It also helps in improving the overall aesthetic well-being of the affected individuals. Understanding and managing oral pigmented lesions is not just a matter of health, but it also contributes to an improved quality of life.