524
Smoker's Melanosis. A Case Report "
Frederic H. Brown, and Glen D. Houston*
Smoker's Melanosis is a benign pigmentation of the oral mucosa, predominantly observed on the attached anterior mandibular gingiva and interdental papillae. These macular lesions are independent of genetic factors, therapeutic medication usage, and various systemic disorders. As a group they are often seen after the third decade of life. Due to the onset in adulthood and the progressive darkening, malignant melanoma must be ruled out. A review of the literature and a case report of this interesting and unique entity is presented. / Periodontol 1991;62:524-527.
Key Words: Mouth neoplasms; melanoma, benign/diagnosis.
Smoker's melanosis is a benign focal pigmentation of the oral mucosa, predominantly involving the attached anterior mandibular gingiva, and not otherwise associated with genetic factors, medical conditions, exogenous pigmentation or use of therapeutic medications.1 Melanosis of the gingiva is frequently encountered among dark-skinned ethnic groups, as well as in medical conditions such as Addison's disease, Albright's syndrome, Peutz-Jeghers syndrome, and von Recklinghausen's disease (neurofibromatosis).2"4 Some medications, particularly antimalarial agents and some tricyclic antidepressants, have also been known to cause oral pigmentation.5,6 The development of focal pigmentation of the oral cavity presents a potential problem for the clinician, particularly if the lesion has an onset later in life and has a progressive darkening, as the condition could be confused with a malignant melanoma.2 In 1977 Hedin1 reported on 30 cases of a localized mucosal melanosis which were not related to the above mentioned conditions, but were associated with tobacco use. He termed this condition as "smoker's melanosis." Although most cases of smoker's melanosis have been observed involving the anterior mandibular gingiva, it can be found in other parts of the oral cavity as well. Additionally, the incidence of these lesions was found to be greater among heavy users of tobacco. This case report deals with a case of smoker's melanosis involving the anterior facial maxillary gingiva. CASE REPORT A 31-year old Caucasian female was referred from the Oral Diagnosis Clinic due to her concern about "a dark spot on my gums which is getting bigger and darker" (Fig. 1). Her *AFSC
Regional Hospital Eglin, Eglin AFB
FL.
tWilford Hall USAF Medical Center, Lackland AFB TX. The opinions expressed are those of the authors, and not necessarily those of the Department of Defense or the United States Air Force.
Figure 1.
Smoker's melanosis
involving the maxillary facial gingiva.
was unremarkable, and she reported that her mother had a history of cancer. On further questioning it was discovered that the carcinoma in question was a basal cell carcinoma of the face, removed without further complication. The patient was further questioned about medications, which she denied taking, inclusive of oral contraceptives. Her medical history was also negative for adrenal, gastroenterologie, and genetic disorders that could produce pigmentation of her mucosa. The only significant finding was her history of tobacco use, which she admitted had significantly increased recently. She further reported holding her cigarette in the area of the gingival pigmentation. The lesion appeared to be localized only on the marginal gingiva. No other darkly pigmented lesions were observed in the oral cavity or skin. The area did not blanche clinically and a radiographie survey of the area in question was unremarkable. The patient had a very gener-
past medical history
Volume 62 Number 8
of keratinized gingiva, and a simple excisional performed without compromising function or esthetics. The patient had an uneventful recovery from the ous zone
biopsy
was
biopsy.
Histopathologic Findings The macroscopic soft tissue specimen measured 10 x 4 4 mm and exhibited an area of submucosal pigmentation.
Microscopically, histological sections stained with hematoxylin and eosin at multiple levels showed a fragment of gingiva composed of stratified squamous epithelium exhibiting a surface layer of parakeratin and submucosa composed of fibrous connective tissue (Fig. 2). Within the basal cell layer of the surface epithelium, numerous aggregates of a brown, granular pigment interpreted as melanin were observed (Fig. 3). Microscopic diagnosis: Right maxillary facial gingiva; excision: benign mucosal melanosis compatible with smoker's melanosis.
DISCUSSION Pigmentation observed involving the oral mucous membrane usually is caused by one of the following entities: 1) vascular lesions (hematoma, varix, and hemangioma); 2) metallic tattoo (usually amalgam); or 3) melanotic lesions (oral melanotic macule, pigmented nevus, malignant melanoma, and various syndromes to include Addison's dis-
Albright's syndrome, Peutz-Jeghers' syndrome, or von Recklinghausen's disease.2"4 A relevant clinical test such as a radiographie survey (examination for radiopaque metallic particles) and appliease,
BROWN,
HOUSTON
525
cation of pressure (blanche) on the area in question can be helpful in narrowing the clinical differential diagnosis. Additionally, a thorough clinical history is essential.7 In this particular case, the patient gave a positive history of heavy cigarette smoking. The above mentioned tests were performed and were unremarkable, thus guiding the clinician to biopsy the pigmented area8'9 and the ultimate diagnosis of smoker's melanosis. With the microscopic confirmation of the presence of melanin, the differential diagnosis was constructed around conditions that produce or represent some form of melanin
deposition.
In 1977 Page and associates8 reported a series of 80 oral melanotic lesions which did not readily fit into existing recognized categories of melanotic lesions. These lesions were found to occur predominantly in the fifth decade of life, were frequently observed in the gingiva, usually solitary, of less than 1 cm in diameter, and occasionally presented as multiple lesions. Microscopically, melanin pigmentation was observed in the basal cell layer and in the lamina propria. These researchers believed that the term oral melanotic macule should be used for these lesions unless a specific cause could be confirmed based upon clinical data. In a subsequent report Büchner and Hansen9 reported 105 new cases of oral melanotic macules, and discussed proper terminology for these lesions. They found that in most patients the melanotic macule was solitary in appearance with the most common location being the vermillion border, followed by the gingiva. This report noted that the melanotic macule was characterized by increased melanin deposition
Figure 2. Pigmented area of the maxillary facial gingiva composed of parakeratinized stratified epithelium and underlying fibrous connective tissue. (H&E x 40.)
squamous
526
SMOKER'S MELANOSIS
J Periodontol August 1991
A REPORT OF A CASE -
Figure 3. Higher magnification of Figure 2. Demonstrates an abundance of a brown, granular pigment interpreted as melanin, randomly dispersed throughout the entire basal cell layer. (H&E x 200) in either the basal cell layer, the lamina propria, or a combination of both locations. These authors suggested that the term melanotic macule be reserved for lesions in which there was a definite clinicopathologic correlation between a clinically pigmented macule and the aforementioned microscopic findings. It is of interest that these authors noted that the etiology of the oral melanotic macule was obscure. In four of the cases they studied, there was an association with a history of trauma. Among the activities noted were chronic cheek chewing, chronic lip biting, and holding a cigarette or pipe in the location of the lesions for years. Melanin pigmentation involving the oral cavity has also been associated with various antimalarial drugs,5-6'1013 quinidine sulfate14 minocycline hydrochloride15-16 and HIVinfected patients.17 These various conditions were excluded based on the patient's past medical history. Pigmented nevi are uncommon oral lesions, but this group of oral lesions as well as the mucosal malignant melanoma were also considered based upon the clinical presentation of this case. The hard palate and the buccal mucosa are the most common locations for pigmented nevi.18 Melanomas of the oral mucosa represent a small percent of all melanomas within the head and neck region, and vary from 0.4% to 4.0%. The most common sites for intraoral melanomas are the hard palate and maxillary gingiva, followed by the lip, soft palate, tongue, buccal mucosa, and sublingual region. Melanomas that occur in the oral cavity also have a tendency to present as multifocal lesions.19 The pigmented nevus and malignant melanoma were ruled out based upon the results of the histologie evaluation.
In Hedin's
original article1 describing
smoker's melan-
osis, it was noted that microscopically this condition dem-
onstrated melanin deposition within the basal cell layer, as well as the lamina propria, not unlike the observations in the oral melanotic macule as described by Page and associates.8 The oral melanotic macule as originally described8 was felt to have an obscure origin. The same condition could result from racial pigmentation, endocrine distur-
bances, antimalarial therapy, Peutz-Jegher's syndrome, hemochromatosis, chronic pulmonary disease, trauma, or
many believed to be idiopathic in origin. It was noted that at least 3 of these cases had a traumatic origin. On the skin, chronic physical trauma and heat are well known to stimulate excessive melanin formation,20 and this same mechanism could apply to oral lesions as well. Page et al.,8 therefore, believed that the majority of these lesions required clinicopathologic correlation for definitive diagnosis and in these instances, the diagnosis should reflect the etiology, (i.e., melanin pigmentation secondary to trauma). For those lesions without an identifiable etiologic factor, they suggested the term oral melanotic macule. In the present case, smoker's melanosis is thus considered to be secondary to tobacco smoking, as described by Hedin,1 and, as such, has an identifiable etiologic agent or factor. This condition, then, could be expected to occur throughout the oral cavity. In the majority of the cases, smoker's melanosis has been observed involving the mandibular mucosa, particularly the labial attached gingiva of the cuspids and incisors.
Volume 62 Number 8
BROWN,
investigate this interesting and unusual encouraged.
Further studies to
entity
are
REFERENCES 1. Hedin CA. Smoker's melanosis. Arch Dermatol
1538. 2. Shafer 3. 4. 5.
6.
7. 8.
9. 10.
1977; 113:1533-
Hine MK, Levy BM. A Textbook of Oral Pathology. W.B. Saunders Co.; 1984:89-136. Wood NK, Goaz PD. Differential Diagnosis of Oral Lesions. St. Louis: The C.V. Mosby Co.; 1975, 172-173. Eversole LR. Clinical Outline of Oral Pathology: Diagnosis and Treatment. Philadelphia: Lea and Febiger; 1984:124. Giansanti JS, Tillery DE, Olansky S. Oral mucosal pigmentation resulting from antimalarial therapy. Oral Surg Oral Med Oral Pathol 1971; 31:66-69. Hedstrand AG. Farmacevtiska Specialiter in Sverige. Uppsala, Sweden: Almqvist & Wiskell, 1976. Kerr DA, Ash MM, Miliard HD. Oral Diagnosis St. Louis: The C.V. Mosby Co.; 1983. Page LR, Corio RL, Crawford BE, Giansanti JS, Weathers DR. The oral melanotic macule. Oral Surg Oral Med Oral Pathol 1977; 44:219226. Büchner A, Hansen LS. Melanotic macule of the oral mucosa. Oral Surg Oral Med Oral Pathol 1979; 48:244-249. Levy H. Chloroquine induced pigmentation. SAfrMedJ 1981; 62:735737.
WG,
Philadelphia:
HOUSTON
527
11. Manor A, Sperling I, Büchner A. Gingival pigmentation associated with antimalarial drugs. IsrJ Dent Med 1981; 25:13-16. 12. Granstein RD, Sober AJ. Drug and heavy metal induced hyperpigmentation. J Am Acad Dermatol 1981; 5:1-18. 13. Moller H. Pigmentary disturbances due to drugs. Acta Derm Venereol 1966; 40:423-431. 14. Main JHP. Two cases of oral pigmentation associated with quinidine therapy. Oral Surg Oral Med Oral Pathol 1988; 66:59-61. 15. Fendrich P, Brooke RL An unusual case of oral pigmentation. Oral Surg Oral Med Oral Pathol 1984; 58:288-291. 16. Cale AE, Freedman PD, Lumerman H. Pigmentation of the jawbones and teeth secondary to minocycline hydrochloride therapy. / Periodontol 1988; 59:112-114. 17. Langford A, Pohle HD, Gelberblom H, Zhang X, Reichart PA. Oral hyperpigmentation in HJV-infected patients. Oral Surg Oral Med Oral Pathol 1989; 67:301-307. 18. Büchner, . Hansen, LS. Pigmented nevi of the oral mucosa: A clinicopathologic study of 36 new cases and review of 155 from the literature. Oral Surg Oral Med Oral Pathol 1987; 63:566-572. 19. Berthelsen A, Andersen A, Jensen T, Hansen H. Melanomas of the mucosa in the oral cavity and upper respiratory passages. Cancer 1984; 54:907-912. 20. Lund HZ, Krauz JM. Melanotic Tumors of the Skin. Washington D.C.: Armed Forces Institute of Pathology 1966; 13-15. Send reprint requests to: Col. Frederic H. Brown, Chief of Periodontology, AFSC Regional Hospital Eglin, Eglin AFB FL 32542-5300. Accepted for publication February 11, 1991.
Smoker's Melanosis. A Case Report "
Frederic H. Brown, and Glen D. Houston*
Smoker's Melanosis is a benign pigmentation of the oral mucosa, predominantly observed on the attached anterior mandibular gingiva and interdental papillae. These macular lesions are independent of genetic factors, therapeutic medication usage, and various systemic disorders. As a group they are often seen after the third decade of life. Due to the onset in adulthood and the progressive darkening, malignant melanoma must be ruled out. A review of the literature and a case report of this interesting and unique entity is presented. / Periodontol 1991;62:524-527.
Key Words: Mouth neoplasms; melanoma, benign/diagnosis.
Smoker's melanosis is a benign focal pigmentation of the oral mucosa, predominantly involving the attached anterior mandibular gingiva, and not otherwise associated with genetic factors, medical conditions, exogenous pigmentation or use of therapeutic medications.1 Melanosis of the gingiva is frequently encountered among dark-skinned ethnic groups, as well as in medical conditions such as Addison's disease, Albright's syndrome, Peutz-Jeghers syndrome, and von Recklinghausen's disease (neurofibromatosis).2"4 Some medications, particularly antimalarial agents and some tricyclic antidepressants, have also been known to cause oral pigmentation.5,6 The development of focal pigmentation of the oral cavity presents a potential problem for the clinician, particularly if the lesion has an onset later in life and has a progressive darkening, as the condition could be confused with a malignant melanoma.2 In 1977 Hedin1 reported on 30 cases of a localized mucosal melanosis which were not related to the above mentioned conditions, but were associated with tobacco use. He termed this condition as "smoker's melanosis." Although most cases of smoker's melanosis have been observed involving the anterior mandibular gingiva, it can be found in other parts of the oral cavity as well. Additionally, the incidence of these lesions was found to be greater among heavy users of tobacco. This case report deals with a case of smoker's melanosis involving the anterior facial maxillary gingiva. CASE REPORT A 31-year old Caucasian female was referred from the Oral Diagnosis Clinic due to her concern about "a dark spot on my gums which is getting bigger and darker" (Fig. 1). Her *AFSC
Regional Hospital Eglin, Eglin AFB
FL.
tWilford Hall USAF Medical Center, Lackland AFB TX. The opinions expressed are those of the authors, and not necessarily those of the Department of Defense or the United States Air Force.
Figure 1.
Smoker's melanosis
involving the maxillary facial gingiva.
was unremarkable, and she reported that her mother had a history of cancer. On further questioning it was discovered that the carcinoma in question was a basal cell carcinoma of the face, removed without further complication. The patient was further questioned about medications, which she denied taking, inclusive of oral contraceptives. Her medical history was also negative for adrenal, gastroenterologie, and genetic disorders that could produce pigmentation of her mucosa. The only significant finding was her history of tobacco use, which she admitted had significantly increased recently. She further reported holding her cigarette in the area of the gingival pigmentation. The lesion appeared to be localized only on the marginal gingiva. No other darkly pigmented lesions were observed in the oral cavity or skin. The area did not blanche clinically and a radiographie survey of the area in question was unremarkable. The patient had a very gener-
past medical history
Volume 62 Number 8
of keratinized gingiva, and a simple excisional performed without compromising function or esthetics. The patient had an uneventful recovery from the ous zone
biopsy
was
biopsy.
Histopathologic Findings The macroscopic soft tissue specimen measured 10 x 4 4 mm and exhibited an area of submucosal pigmentation.
Microscopically, histological sections stained with hematoxylin and eosin at multiple levels showed a fragment of gingiva composed of stratified squamous epithelium exhibiting a surface layer of parakeratin and submucosa composed of fibrous connective tissue (Fig. 2). Within the basal cell layer of the surface epithelium, numerous aggregates of a brown, granular pigment interpreted as melanin were observed (Fig. 3). Microscopic diagnosis: Right maxillary facial gingiva; excision: benign mucosal melanosis compatible with smoker's melanosis.
DISCUSSION Pigmentation observed involving the oral mucous membrane usually is caused by one of the following entities: 1) vascular lesions (hematoma, varix, and hemangioma); 2) metallic tattoo (usually amalgam); or 3) melanotic lesions (oral melanotic macule, pigmented nevus, malignant melanoma, and various syndromes to include Addison's dis-
Albright's syndrome, Peutz-Jeghers' syndrome, or von Recklinghausen's disease.2"4 A relevant clinical test such as a radiographie survey (examination for radiopaque metallic particles) and appliease,
BROWN,
HOUSTON
525
cation of pressure (blanche) on the area in question can be helpful in narrowing the clinical differential diagnosis. Additionally, a thorough clinical history is essential.7 In this particular case, the patient gave a positive history of heavy cigarette smoking. The above mentioned tests were performed and were unremarkable, thus guiding the clinician to biopsy the pigmented area8'9 and the ultimate diagnosis of smoker's melanosis. With the microscopic confirmation of the presence of melanin, the differential diagnosis was constructed around conditions that produce or represent some form of melanin
deposition.
In 1977 Page and associates8 reported a series of 80 oral melanotic lesions which did not readily fit into existing recognized categories of melanotic lesions. These lesions were found to occur predominantly in the fifth decade of life, were frequently observed in the gingiva, usually solitary, of less than 1 cm in diameter, and occasionally presented as multiple lesions. Microscopically, melanin pigmentation was observed in the basal cell layer and in the lamina propria. These researchers believed that the term oral melanotic macule should be used for these lesions unless a specific cause could be confirmed based upon clinical data. In a subsequent report Büchner and Hansen9 reported 105 new cases of oral melanotic macules, and discussed proper terminology for these lesions. They found that in most patients the melanotic macule was solitary in appearance with the most common location being the vermillion border, followed by the gingiva. This report noted that the melanotic macule was characterized by increased melanin deposition
Figure 2. Pigmented area of the maxillary facial gingiva composed of parakeratinized stratified epithelium and underlying fibrous connective tissue. (H&E x 40.)
squamous
526
SMOKER'S MELANOSIS
J Periodontol August 1991
A REPORT OF A CASE -
Figure 3. Higher magnification of Figure 2. Demonstrates an abundance of a brown, granular pigment interpreted as melanin, randomly dispersed throughout the entire basal cell layer. (H&E x 200) in either the basal cell layer, the lamina propria, or a combination of both locations. These authors suggested that the term melanotic macule be reserved for lesions in which there was a definite clinicopathologic correlation between a clinically pigmented macule and the aforementioned microscopic findings. It is of interest that these authors noted that the etiology of the oral melanotic macule was obscure. In four of the cases they studied, there was an association with a history of trauma. Among the activities noted were chronic cheek chewing, chronic lip biting, and holding a cigarette or pipe in the location of the lesions for years. Melanin pigmentation involving the oral cavity has also been associated with various antimalarial drugs,5-6'1013 quinidine sulfate14 minocycline hydrochloride15-16 and HIVinfected patients.17 These various conditions were excluded based on the patient's past medical history. Pigmented nevi are uncommon oral lesions, but this group of oral lesions as well as the mucosal malignant melanoma were also considered based upon the clinical presentation of this case. The hard palate and the buccal mucosa are the most common locations for pigmented nevi.18 Melanomas of the oral mucosa represent a small percent of all melanomas within the head and neck region, and vary from 0.4% to 4.0%. The most common sites for intraoral melanomas are the hard palate and maxillary gingiva, followed by the lip, soft palate, tongue, buccal mucosa, and sublingual region. Melanomas that occur in the oral cavity also have a tendency to present as multifocal lesions.19 The pigmented nevus and malignant melanoma were ruled out based upon the results of the histologie evaluation.
In Hedin's
original article1 describing
smoker's melan-
osis, it was noted that microscopically this condition dem-
onstrated melanin deposition within the basal cell layer, as well as the lamina propria, not unlike the observations in the oral melanotic macule as described by Page and associates.8 The oral melanotic macule as originally described8 was felt to have an obscure origin. The same condition could result from racial pigmentation, endocrine distur-
bances, antimalarial therapy, Peutz-Jegher's syndrome, hemochromatosis, chronic pulmonary disease, trauma, or
many believed to be idiopathic in origin. It was noted that at least 3 of these cases had a traumatic origin. On the skin, chronic physical trauma and heat are well known to stimulate excessive melanin formation,20 and this same mechanism could apply to oral lesions as well. Page et al.,8 therefore, believed that the majority of these lesions required clinicopathologic correlation for definitive diagnosis and in these instances, the diagnosis should reflect the etiology, (i.e., melanin pigmentation secondary to trauma). For those lesions without an identifiable etiologic factor, they suggested the term oral melanotic macule. In the present case, smoker's melanosis is thus considered to be secondary to tobacco smoking, as described by Hedin,1 and, as such, has an identifiable etiologic agent or factor. This condition, then, could be expected to occur throughout the oral cavity. In the majority of the cases, smoker's melanosis has been observed involving the mandibular mucosa, particularly the labial attached gingiva of the cuspids and incisors.
Volume 62 Number 8
BROWN,
investigate this interesting and unusual encouraged.
Further studies to
entity
are
REFERENCES 1. Hedin CA. Smoker's melanosis. Arch Dermatol
1538. 2. Shafer 3. 4. 5.
6.
7. 8.
9. 10.
1977; 113:1533-
Hine MK, Levy BM. A Textbook of Oral Pathology. W.B. Saunders Co.; 1984:89-136. Wood NK, Goaz PD. Differential Diagnosis of Oral Lesions. St. Louis: The C.V. Mosby Co.; 1975, 172-173. Eversole LR. Clinical Outline of Oral Pathology: Diagnosis and Treatment. Philadelphia: Lea and Febiger; 1984:124. Giansanti JS, Tillery DE, Olansky S. Oral mucosal pigmentation resulting from antimalarial therapy. Oral Surg Oral Med Oral Pathol 1971; 31:66-69. Hedstrand AG. Farmacevtiska Specialiter in Sverige. Uppsala, Sweden: Almqvist & Wiskell, 1976. Kerr DA, Ash MM, Miliard HD. Oral Diagnosis St. Louis: The C.V. Mosby Co.; 1983. Page LR, Corio RL, Crawford BE, Giansanti JS, Weathers DR. The oral melanotic macule. Oral Surg Oral Med Oral Pathol 1977; 44:219226. Büchner A, Hansen LS. Melanotic macule of the oral mucosa. Oral Surg Oral Med Oral Pathol 1979; 48:244-249. Levy H. Chloroquine induced pigmentation. SAfrMedJ 1981; 62:735737.
WG,
Philadelphia:
HOUSTON
527
11. Manor A, Sperling I, Büchner A. Gingival pigmentation associated with antimalarial drugs. IsrJ Dent Med 1981; 25:13-16. 12. Granstein RD, Sober AJ. Drug and heavy metal induced hyperpigmentation. J Am Acad Dermatol 1981; 5:1-18. 13. Moller H. Pigmentary disturbances due to drugs. Acta Derm Venereol 1966; 40:423-431. 14. Main JHP. Two cases of oral pigmentation associated with quinidine therapy. Oral Surg Oral Med Oral Pathol 1988; 66:59-61. 15. Fendrich P, Brooke RL An unusual case of oral pigmentation. Oral Surg Oral Med Oral Pathol 1984; 58:288-291. 16. Cale AE, Freedman PD, Lumerman H. Pigmentation of the jawbones and teeth secondary to minocycline hydrochloride therapy. / Periodontol 1988; 59:112-114. 17. Langford A, Pohle HD, Gelberblom H, Zhang X, Reichart PA. Oral hyperpigmentation in HJV-infected patients. Oral Surg Oral Med Oral Pathol 1989; 67:301-307. 18. Büchner, . Hansen, LS. Pigmented nevi of the oral mucosa: A clinicopathologic study of 36 new cases and review of 155 from the literature. Oral Surg Oral Med Oral Pathol 1987; 63:566-572. 19. Berthelsen A, Andersen A, Jensen T, Hansen H. Melanomas of the mucosa in the oral cavity and upper respiratory passages. Cancer 1984; 54:907-912. 20. Lund HZ, Krauz JM. Melanotic Tumors of the Skin. Washington D.C.: Armed Forces Institute of Pathology 1966; 13-15. Send reprint requests to: Col. Frederic H. Brown, Chief of Periodontology, AFSC Regional Hospital Eglin, Eglin AFB FL 32542-5300. Accepted for publication February 11, 1991.
