Black and Brown: Non-neoplastic Pigmentation of the Oral Mucosa

Oral Melanoma in Older Adults: Epidemiology, Molecular Landscape, and Treatment Strategies

Oral melanoma is an aggressive neoplasm arising from melanocytes in the mucosal epithelium, accounting for 0.2%-0.8% of all melanomas. Unlike cutaneous melanoma, it is not associated with UV exposure, and its pathogenesis involves complex genetic and molecular alterations. This neoplasm predominantly affects older adults (≥ 60 years). Clinically, lesions often present as macular or nodular with an exophytic growth pattern, sometimes ulcerated, and exhibit varied pigmentation. Diagnosis is further complicated by non-pigmented (amelanotic) variants that can resemble other oral pigmentations. Wide surgical excision remains the mainstay treatment, often combined with chemotherapy; however, recurrence and distant metastasis remain high. While immunotherapy has shown promise in other melanoma subtypes, its efficacy in oral melanoma remains uncertain. Treatment in older adults is particularly challenging due to comorbidities and treatment-related morbidity. This review summarizes the epidemiology, clinical features, and current treatment strategies for oral melanoma in older adults. Key advances in the molecular mechanisms underlying this neoplasm are also outlined. As a strategic approach, integrating oral melanoma screening into routine geriatric dental care, supported by diagnostic algorithms, may improve early detection, prognosis, and survival outcomes in this vulnerable population.

Prevalence and associated factors of oral pigmented lesions among Yemeni dental patients: a large cross-sectional study

BACKGROUND

The literature is scarce and inconsistent regarding the prevalence, types, and risk factors of oral pigmented lesions (OPL). The present study investigated the prevalence, types, and distribution of OPL, as well as their associated factors among Yemeni dental patients.

METHODS

This cross-sectional study was conducted among 1920 dental patients attending the dental clinics, Sanaa University, Yemen over a period of 10 months (from March to December 2021). A comprehensive clinical examination was conducted by a well-trained and calibrated examiner, and histopathological analysis was carried out in suspicious cases.

RESULTS

Out of the 1920 subjects, 1091 (56.8%) were diagnosed with one or more OPL. The most common OPL were physiologic pigmentations (33.8%), smoker's melanosis (14.6%), melanotic macule (2.6%), and vascular-related pigmentations (varix, hemangioma, hematoma). Gingiva and buccal mucosa were the most involved sites. Male subjects showed higher prevalence of smoker's melanosis, black hairy tongue, vascular-related pigmentations, whereas physiologic pigmentation, melanotic macule and melanotic nevi were more common in females. The results revealed that being male (p < 0.001), over 40 years old (p = 0.001), smoker (p < 0.001), waterpipe smoker (p = 0.004), and being dark-skinned (p < 0.001) are determinant factors for the occurrence of OPLs.

CONCLUSION

The prevalence of OPL among Yemeni population is high, with the gingiva and buccal mucosae are the most common sites of oral pigmentations. Male gender, smoking habits, and dark skin complexion are risk factors for developing OPLs. Understanding the etiology and clinical features of common OPL is paramount for accurate diagnosis and management of these lesions.

Descriptive study on oral health and pathologies in vulnerable migrant adolescents from North and West Africa

This descriptive study focuses on the oral health of African migrants, especially adolescents, arriving in the Canary Islands. Notably, these patients show a high prevalence of caries and oral mucosal alterations. These are influenced by multifactorial factors, such as living conditions in their country of origin, hygiene habits, and sugar-rich diets. Furthermore, it is worth noting the need for inclusive oral health policies in receiving countries and the need to develop oral health care protocols in regions with migratory flows to effectively address oral health needs and facilitate the integration of migrants. We included 104 migrant patients from different African countries, mainly from North and West Africa, and analyzed their oral health status. We found that 89.4% of the patients had dental caries, with a higher prevalence in North Africa. Moreover, 25% of patients showed oral mucosal alterations, with leukoedema being the most common condition. Regarding malocclusions, 42.6% of patients had Class I malocclusion and only 15.4% had dental crowding. Regarding intraosseous lesions, 97.1% of the patients had no lesions and most did not require dental prostheses. This study provides a detailed overview of the oral health conditions of African migrants in the Canary Islands.

Lip Melanosis Postdermal Filler Injection: Second Case Report and Literature Review

Oral pigmentation can arise from various factors, including physiological and pathological, or as a manifestation of an underlying systemic disease. We present an atypical case of dermal filler-related complication, in which clinical lip pigmentation was observed. This condition can pose a diagnostic challenge in accurately identifying its cause.

Black Hairy Tongue Observed During Esophagogastroduodenoscopy

Black hairy tongue, also known as lingua villosa nigra, is a benign oral condition characterized by a dark discoloration and "hairy" appearance on the tongue's dorsal surface, resulting from elongated filiform papillae. This condition is associated with risk factors such as smoking, poor oral hygiene, and diabetes, which increase susceptibility to microbial colonization, particularly by Candida species. Although commonly diagnosed by visual inspection, black hairy tongue is infrequently observed during endoscopic procedures. We report a case of a 69-year-old Japanese man with poorly controlled type 2 diabetes (hemoglobin A1c of 9.7%) and a significant smoking history of 49 pack-years. During a routine esophagogastroduodenoscopy, a dark lesion was detected on the dorsal surface of the tongue. Detailed imaging and biopsy revealed elongated papillae with fungal hyphae, confirming a diagnosis of candidiasis. This case underscores the value of esophagogastroduodenoscopy and histopathological examination in diagnosing black hairy tongue and distinguishing it from other pigmented lesions. Recognizing black hairy tongue as a potential finding during endoscopy may aid in prompt diagnosis, especially in patients with predisposing factors like smoking and diabetes.

Oral lesions associated with imatinib mesylate therapy: five new cases and a literature review

This study aimed to report the collective clinical characteristics of oral side effects associated with imatinib therapy according to age, sex, and clinical condition. A bibliographic review was performed using the PubMed, Web of Science, Scopus, Cochrane Library, and Embase databases. Forty-five cases of oral side effects due to imatinib therapy were identified in the literature. With the addition of five new cases seen at the authors' institution, a total of 50 cases were analysed. Of the five new cases, four with gastrointestinal stromal tumours developed oral lichenoid lesions (OLLs), and one with chronic myeloid leukaemia (CML) developed oral hyperpigmentation (OHP). Of the total 50 patients, 26 were male and 24 were female, and age ranged from 29 to 86 years. Most patients were ≥50 years old (80%); only three patients were jaw was the least common, with just five cases (10%). Among the patients with OHP, the predominant clinical condition was CML (22 cases, 91.7%). In conclusion, the possibility of oral side effects needs to be considered during the examination of patients receiving imatinib therapy.

Differential Diagnosis of Pigmented Lesions in the Oral Mucosa: A Clinical Based Overview and Narrative Review

This paper examines the clinical differentiation of pigmented lesions in the oral mucosa, which poses significant diagnostic challenges across dental and medical disciplines due to their spectrum from benign to potentially malignant conditions. Through a literature review and analysis of clinical cases, this study clarifies current diagnostic methodologies, with an emphasis on differential diagnosis, to provide a practical guide for clinicians. The classification of pigmented lesions, such as endogenous, focal melanocytic, and multifocal pigmentation, based on clinical and histological features, highlights the necessity for a structured and informed approach. A retrospective examination of cases from our oral medicine and pathology clinic, coupled with analysis of photographic and histological records, aids in classifying these lesions. This fosters a better understanding and promotes informed discussions among clinicians, ultimately aiming to enhance early and precise diagnosis, thus improving patient management and outcomes.

Gingivectomy-Gingivoplasty for Oral Physiological Melanosis Depigmentation: A Case Report Involving Human Papillomavirus

Gingiva hyperpigmentation resulting from physiological melanosis causes aesthetic discomfort and is usually perceived as a disease by patients because healthy attached gingiva is typically characterized by coral pink coloring with stippling and scalloped contours. When physiological melanosis compromises the aesthetics of smiling, it may induce insecurity in patients, who usually seek out alternatives for reducing or eliminating hyperpigmentation. We present a case report of a surgical procedure combining gingivectomy with gingivoplasty for the management of physiological melanosis. The surgical procedure was performed on a 40-year-old female patient with bilateral pigmentation in both arches. The results of the histological analysis confirm the diagnoses of melanotic macula, with papillary hyperplasia and cytopathic changes being suggestive of HPV infection, which was verified using an immunohistochemistry analysis based on the detection of a major capsid protein of HPV. Acceptable functional and aesthetic results were obtained for the patient without major discomfort during the postoperative period. In cases when HPV infection is present, long-term follow-up becomes necessary.

Citalopram-Induced Oral Melanotic Macules in a Female Patient and a Review of the Literature

Pigmented lesions in the oral cavity can arise from the accumulation of external substances or internal pigments, resulting in black or brown discoloration. The etiology can be categorized as physiologic, reactive, neoplastic, idiopathic, or indicative of systemic illness. Several systemic drugs have been linked to the development of oral and/or cutaneous pigmentation, either by stimulating the production of melanin or by the accumulation of the drug or its byproducts. The medications most commonly associated with this condition include antimalarials, hormones, oral contraceptives, phenothiazines, chemotherapeutics, amiodarone, minocycline, zidovudine, clofazimine, and ketoconazole. The aim of this case report is to illustrate the drug-induced appearance of multiple melanotic macules in an 89-year-old female patient. The patient was referred to the Department of Oral Medicine and Pathology, School of Dentistry, Aristotle University of Thessaloniki, Greece, complaining of the recent and constant appearance of black spots in her oral cavity. Her medical history revealed a multitude of prescribed drugs, with citalopram being the most recently prescribed one, approximately one year prior to the examination. The clinical examination revealed multiple melanotic macules, on the upper and lower lip as well as on the hard and soft palate. Based on these findings, a biopsy of a melanotic macule of the lip was carried out. The histopathological examination showed that the basal layer of the stratified squamous epithelium exhibited hyperpigmentation (melanin-pigmented basal cells). In addition, scattered melaninophages were noted in lamina propria. Psychotropic drugs associated with cutaneous hyperpigmentation include citalopram. Therefore, our case constitutes an exception since citalopram induced intraoral and perioral, instead of cutaneous, hyperpigmentation.

Evaluation of Oral Mucosal Lesions in Iranian Smokers and Non-smokers

BACKGROUND

Tobacco smoking statistics are alarming and the oral mucosa is the first human part of the body that is exposed to the toxic substances of smoking.

AIMS

Considering the high prevalence rate of tobacco-associated problems in the oral cavity and few studies on the Iranian population regarding the effects of smoking on the oral cavity, this study aimed to evaluate the relationship between smoking and oral lesions in the Iranian population.

MATERIALS AND METHODS

Observational study. In this observational study, the oral cavities of 200 participants (smokers = 100 and non-smokers = 100) were examined by a trained dental student under the supervision of an oral and maxillofacial medicine expert, and the presence of coated tongue, leukoedema, leukoplakia, smoker's palate, smoker's melanosis, erythroplakia, frictional hyperkeratosis, acute pseudomembranous candidiasis, and erythematous candidiasis were recorded. Xerostomia was evaluated based on participants' self-reporting through a questionnaire. All data were analyzed using T-test, Chi-square test, odd ratio, 95% confidence interval, Fisher's exact test, and Spearman's rank correlation coefficient.

RESULTS

The results of this study showed smoking is significantly associated with an increased risk of coated tongue (OR: 1.80, 95% CI: 1.32-3.54, P = 0.005), smoker's melanosis (OR: 6.176, 95% CI: 3.28-11.62, P = 0.00002), and frictional hyperkeratosis (OR: 1.33, 95% CI: 0.68-2.60, P = 0.005). However, no significant association was observed between smoking and leukoedema (OR: 1, 95% CI: 0.51-1.94, P = 1). None of the participants presented smoker's palate, erythroplakia, and candidiasis.

CONCLUSIONS

This study's results showed that smokers exhibited a greater chance of developing oral lesions compared to non-smokers.

Efficacy and Risks of Different Treatments for Oral Hyperpigmentation: A Systematic Review and Network Meta-Analysis

BACKGROUND

Oral-pigmented lesions have raised aesthetic concerns, leading to multiple depigmentation techniques. This systematic review and network meta-analysis aimed to assess the efficacy of different treatments for oral hyperpigmentation.

METHODS

A computerized search was conducted on Science Direct, Medline via PubMed, Scopus, and Web of Science using the relevant keywords. English-language studies published between 2013 and 2023 that focused on patients with oral pigmented lesions subjected to different treatment modalities, such as laser or surgical intervention, were compared to determine their efficacy and safety profile. Data were analyzed using R software, applying frequentist models.

RESULTS

A total of 27 studies were included. In contrast to the CO2 laser, Er: YAG laser was linked to a higher risk of bleeding (RR = 2.73, p < 0.01), whereas the diode laser had the most favorable score in minimizing bleeding index (P-score = 0.86). In terms of lower risk and postoperative pain score (RR = 0.01, p < 0.01), the Er,Cr:YSGG laser had the most favorable result (P-score = 1.00). The Er: YAG laser demonstrated the highest probability of preventing recurrence (RR = 0.28, p < 0.01), followed by the diode laser (RR = 0.42, p < 0.01).

CONCLUSIONS

The choice of treatment for oral pigmentation should be based on individual patient needs and the desired outcomes. The Er: YAG laser seems highly effective in preventing pigment recurrence, the diode laser emerges as a top contender in managing bleeding risks, and the Er,Cr:YSGG laser is particularly efficacious in managing postoperative pain.

Unilateral Hyperpigmented Facial Lesion Since Birth

Facial hyperpigmented lesions that are unilateral are a rare and challenging dermatological anomaly since birth which can be genetic and non-genetic. This paper seeks to provide an exhaustive overview of the etiology, clinical presentation, differential diagnosis, and management strategies for these congenital lesions. Unilateral facial hyperpigmented lesions can be caused by a number of conditions, such as congenital melanocytic nevi, Becker's nevus, nevus of Ota, linear epidermal nevi, and café-au-lait macules. Accurate diagnosis requires meticulous examination, dermoscopy, and histopathological evaluation. Observation, topical therapies, surgical excision, and laser therapy are among the available treatment options. Treatment decisions should be influenced by factors such as lesion characteristics, aesthetic concerns, and patient preferences. Long-term supervision and psychosocial support are indispensable elements of comprehensive management. We present a case of a 12-year-old patient with a progressively growing hyperpigmented lesion on the right side of the face, present since birth with an intermittent area of normal skin in between. Dermoscopy unveiled an irregular, dark brown pigment network, and histopathological evaluation showed an increased number of melanocytes in the dermis. This case highlights the diagnostic challenges of such lesions and underscores the significance of a multidisciplinary approach for accurate evaluation and management. This paper aims to cover existing knowledge gaps regarding unilateral facial hyperpigmented lesions since birth and direct future research efforts for diagnostic and therapeutic interventions.

Black hairy tongue after alprazolam intake

Key Clinical Message

A 31-year-old female with a diagnosis of bipolar disorder developed black hairy tongue after alprazolam therapy. Her symptom resolved 10 days after the cessation of alprazolam.

Abstract

Alprazolam is a widely used antidepressant and antianxiety drug. Mild to moderate side effect of alprazolam was commonly seen, including lethargy, dizziness, headache, dry mouth, nausea, fatigue, constipation, and blurred vision. In this case, we reported a patient developed black hairy tongue after alprazolam intake, and her symptom resolved after 10-day discontinuation of alprazolam. This rare adverse event should be of concern to clinicians. This is the first paper to report an alprazolam-induced BHT. This rare side effect of alprazolam should be concern of clinicians; we hope our report will promote the understand of BHT and acknowledge clinicians of this rare side effect of alprazolam.

Melanoma in skin of color: Part I. Epidemiology and clinical presentation

Although there is a higher incidence of melanoma among non-Hispanic White individuals, melanoma is diagnosed at more advanced stages and associated with worse survival rates among individuals with skin of color (SOC). The proportions of melanoma subtypes differ across racial groups, with acral lentiginous melanoma and mucosal melanoma representing higher proportions of melanoma diagnoses in individuals with SOC compared to White individuals. The recognition of distinct differences in anatomic locations and dermatoscopic patterns may facilitate the appropriate differentiation of physiologic from pathologic pigmentation. The first article of this continuing medical education series will focus on the epidemiology and clinical presentation of melanoma in individuals with SOC, with the aim of improving early diagnoses and clinical outcomes.

Oral hyperpigmentation as an adverse effect of highly active antiretroviral therapy in HIV patients: A systematic review and pooled prevalence

Background

Human Immunodeficiency Virus (HIV) infects patients via CD4+ cells which are later be destroyed subsequently causing the deteriotation of immune system. HIV generally manifests in the oral cavity as the first indicating sign and a marker of disease progression. HAART medications are used to reduce the incidence of oral manifestations, however it can also generate adverse effects in the oral cavity including oral hyperpigmentation. This review aimed to estimate the prevalence of oral hyperpigmentation which affect individual quality of life as a side effect of HAART.

Material and Methods

This systematic review applied Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020. Literature search was performed in ScienceDirect, PubMed, and Scopus by combining terms such as highly active antiretroviral therapy, oral manifestation, epidemiology or prevalence published between January 1998 to March 2022.

Results

Of 108 articles, eleven articles were included for systematic review and meta-analysis. The pooled prevalence of oral hyperpigmentation in HAART patients was 25% (95% CI: 11%, 38%; I2: 99%). Subgroup analysis based on geographical location showed varied result may be due to the type and duration of HAART used in study population. The most widely used type of ARV was from the NRTI group (n=7) and the study with the shortest duration showed the lowest oral hyperpigmentation prevalence (n=7).

Conclusions

There is an increased prevalence of oral hyperpigmentation by the use of HAART. Future study should investigate the correlation between HAART duration and the degree of oral hyperpigmentation. Key words:HAART, oral hyperpigmentation; pooled prevalence.

Congenital Melanotic Macule of the Tongue: Report of Two Cases and Literature Review

BACKGROUND

Congenital melanotic macule of the tongue (CMMT) has been described as a distinct entity, despite its unknown etiology. However, the diagnosis and management of affected newborns may challenge clinicians and pediatric dentists.

METHODS

We document here the clinicopathological findings of two additional cases of CMMT. A literature review of CMMT reports identified across PubMed, Web of Science, Embase, and Scopus was also conducted.

RESULTS

The patients, 2- and 4 month-old Venezuelan boys, respectively, presented at birth with a single or multiple dark-brown-pigmented macule exclusively on the dorsum of the tongue. Histopathological features revealed increased melanin pigmentation in the basal epithelial layer with overlying hyperkeratosis and pigment-laden subepithelial macrophages with normal morphological appearance. Nine studies comprising 17 cases of CMMT have been described hitherto. Most cases were from the USA and France (n = 6 each). Twelve (70.6%) patients were males, eight (50%) were white, and median age was 2.7 months. CMMT presented as brownish to black, solitary or multiple pigmentations located in the right or left region of the dorsum of the tongue, ranging in size from 3.0 to 30.0 mm.

CONCLUSION

An important feature for the diagnosis of CMMT is the information about the manifestation at birth and consequent proportional growth. This report intends to draw the attention of pediatricians and dentists to this apparently underdiagnosed condition for decision-making and management of affected newborns.

Pigmented Lesions of the Oral Cavity

Pigmented lesions are a common finding in the oral cavity. Oral pigmented lesions may range from solitary to multiple, pinpoint to diffuse, and have a variety of clinical implications. Nearly all solitary pigmented lesions require a biopsy to rule out mucosal melanoma. Oral mucosal melanoma has a grim prognosis and early discovery is of utmost importance. Multiple pigmented lesions in the oral cavity may indicate a systemic condition about which the patient may not be aware. The presentation and management of these various lesions is the focus of this article.

Disorders of hyperpigmentation. Part I. Pathogenesis and clinical features of common pigmentary disorders

Disorders of hyperpigmentation are common and, depending on the extent and location of involvement, can affect the quality of life and pose a significant psychologic burden for patients. Given the similarities in presentation of the various causes of hyperpigmentation, it is often difficult to elucidate the etiology of these conditions, which is important to guide management. Furthermore, certain disorders, such as lichen planus pigmentosus and ashy dermatosis, have similar clinical and/or histologic presentations, and their classification as distinct entities has been debated upon, leading to additional confusion. In this review, the authors selected commonly encountered disorders of hyperpigmentation of the skin, subdivided into epidermal, dermal, or mixed epidermal-dermal disorders based on the location of pigment deposition, along with disorders of hyperpigmentation of the mucosa and nails. Melanocytic nevi, genetic disorders, and systemic causes of hyperpigmentation were largely excluded and considered to be outside the scope of this review. We discussed the pathogenesis of hyperpigmentation as well as the clinical and histologic features of these conditions, along with challenges encountered in their diagnosis and classification. The second article in this 2-part continuing medical education series focuses on the medical and procedural treatments of hyperpigmentation.

Assessment of the Possible Correlation between the Presence of Helicobacter Pylori Infection and Hairy Tongue Lesion in a Group of Patients in Syria: A Cross-Sectional and Pilot Study

BACKGROUND

This study aimed to evaluate the correlation between the presence of hairy tongue and H. pylori infection in patients referring to their blood test based on the serum levels of anti-H pylori IgG antibodies.

METHODS

This cross-sectional study was conducted in the Department of Oral Medicine, University of Damascus Dental School, between February 2021 and January 2022. The sample size of 40 patients (23 males, 17 females), whose ages ranged from 20-79 years with a mean age of 41.5 ± 12 years, was calculated using the G*power 3.1.3, with a statistical power of 80% and a significance level of 0.05. The hairy tongue index was assessed by a visual method based on observing the dorsum tongue appearance. Then, a blood test was performed to detect the presence of H. pylori by Immulite 2000 XPi. Statistical analysis was performed using SPSS software 22.0, Chi-square.

RESULTS

The prevalence of hairy tongue was higher among males (75%) as compared to females (25%) and was found to be statistically significant (p = 0.026). The hairy tongue lesions were found to be least in the 20-39 age group and most prevalent in the 40-59 age group, without statistically significant correlation. H. pylori infection was detected positive in 70% and negative in 30% of hairy tongue patients, compared to the control group, where the rates were 15% and 85%, respectively, with a statistically significant correlation between infection with H. pylori and hairy tongue (p = 0.001).

CONCLUSION

Our results strongly suggest that the hairy tongue might be considered an indicator of H. pylori infection.

Laugier-Hunziker Syndrome: A Rare Cause of Oral Mucosa Pigmentation

Introduction: Various diseases cause pigmentation of the oral mucosa. Among them, however, Laugier-Hunziker syndrome is not well known to dentists. Laugier-Hunziker syndrome is a benign pigmentary disorder characterized by the unique expression of pigmentation of the mucosa, nails and skin. In this report, we present a rare case of Laugier-Hunziker syndrome that occurred in an elderly person. Case Presentation: The patient was an 84-year-old female resident of an elderly care facility. The institutional dental hygienist reported that she was concerned about the discoloration of the oral mucosa. On examination, she had pigmentation of her oral mucosa and nails. She had no history of any disease or medication that would cause pigmentation. Although this condition was initially unknown to us, a diagnosis of Laugier-Hunziker syndrome was made. Conclusion: We report a case of Laugier-Hunziker syndrome in an elderly woman, which is not a well-known condition among dental professionals. More knowledge about diseases that cause pigmentation of the oral mucosa would be helpful in dental practice, especially at external facilities.

Gingival Pigmentation Removal With a High-Power Diode Laser in Non-contact Mode: A Proposed Technique With Two Years of Follow-Up

This case report describes the efficacy and advantages of using a high-power diode laser in non-contact mode to remove racial melanin pigmentation from the oral mucosa in an aesthetically sensible area to reduce thermal damage and promote better postoperative results. In the presented case, the lesion was removed under local anesthesia in a single session using high-power diode equipment with circular movements over the lesion (10 seconds maximum for each irradiation cycle, with 30 seconds for thermal relaxation, for a total of two cycles), maintaining an average distance of 2-3 mm from the target tissue without fiber activation (continuous wave, 2 W, delivered by quartz fiber with 300 µ). The patient did not report immediate postoperative pain; however, analgesic use was recorded during the first day after the surgical procedure. The biological response and cosmetic results were satisfactory, with proper lesion removal and adequate cicatrization observed during a two-year follow-up period, without complications or compromise of periodontal tissue esthetics.

Global prevalence of oral pigmentation and its related factors: a systematic review and meta-analysis

BACKGROUND

Oral pigmentation is due to the accumulation of one or more pigments in tissues, causing changes in the color of the oral mucosal surfaces. Understanding the exact global prevalence of oral pigmentation and its associated factors helps researchers make the proper interventions at the right time; in this respect, the objective of the present systematic review and meta-analysis was to determine the global prevalence of oral pigmentation and its related factors.

METHOD

A systematic review and meta- analysis were conducted using the following databases: Magiran, SID, Scopus, Embase, PubMed, Web of Science (WoS), and Google Scholar. The search was run to retrieve articles published from inception until July 2021, and the following keywords were applied in the search strategy: "Epidemiolo*", "Prevalen*", "Factor*", "Pigment*", "Mouth", and "Oral". The I² index was used to assess the heterogeneity of the studies, and Egger's test was used to examine the publication bias.

RESULTS

Sixty-nine articles, with a sample size of 70,668 people, meeting the inclusion criteria were included in the study. The pooled of prevalence of oral pigmentation was estimated to be 20.8% (95% confidence interval: 17.1-1.25%). The prevalence of oral pigmentation raised significantly towards the end of the timespan covered by the study (P˂ 0.001). The majority of the examined studies reported that the prevalence of oral pigmentation is significantly higher in men, smokers or those exposed to secondhand smoke, people with fair skin, and who were affected by Yusho patients.

CONCLUSION

The results of the present study show that the prevalence of oral pigmentation is high, with higher prevalence in men, smokers or those exposed to cigarette smoke, people with fair skin, and Yusho patients compared to other groups. It is recommended that. these findings be used in policy makers' decisions to deliver better health care.

New Approach to Addison Disease: Oral Manifestations Due to Endocrine Dysfunction and Comorbidity Burden

This review highlights oral anomalies with major clinical impact in Addison disease (AD), including dental health and dermatologic features, through a dual perspective: pigmentation issues and AD comorbidities with oral manifestations. Affecting 92% of AD patients, cutaneomucosal hyperpigmentation is synchronous with or precedes general manifestations by up to a decade, underlying melanocytic infiltration of the basal epidermal layer; melanophages in the superficial dermis; and, rarely, acanthosis, perivascular lymphocytic infiltrate, and hyperkeratosis. Intraoral pigmentation might be the only sign of AD; thus, early recognition is mandatory, and biopsy is helpful in selected cases. The buccal area is the most affected location; other sites are palatine arches, lips, gums, and tongue. Pigmented oral lesions are patchy or diffuse; mostly asymptomatic; and occasionally accompanied by pain, itchiness, and burn-like lesions. Pigmented lingual patches are isolated or multiple, located on dorsal and lateral areas; fungiform pigmented papillae are also reported in AD individuals. Dermoscopy examination is particularly indicated for fungal etiology; yet, it is not routinely performed. AD’s comorbidity burden includes the cluster of autoimmune polyglandular syndrome (APS) type 1 underlying AIRE gene malfunction. Chronic cutaneomucosal candidiasis (CMC), including oral CMC, represents the first sign of APS1 in 70–80% of cases, displaying autoantibodies against interleukin (IL)-17A, IL-17F ± IL-22, and probably a high mucosal concentration of interferon (IFN)-γ. CMC is prone to systemic candidiasis, representing a procarcinogenic status due to Th17 cell anomalies. In APS1, the first cause of mortality is infections (24%), followed by oral and esophageal cancers (15%). Autoimmune hypoparathyroidism (HyP) is the earliest endocrine element in APS1; a combination of CMC by the age of 5 years and dental enamel hypoplasia (the most frequent dental complication of pediatric HyP) by the age of 15 is an indication for HyP assessment. Children with HyP might experience short dental roots, enamel opacities, hypodontia, and eruption dysfunctions. Copresence of APS-related type 1 diabetes mellitus (DM) enhances the risk of CMC, as well as periodontal disease (PD). Anemia-related mucosal pallor is related to DM, hypothyroidism, hypogonadism, corresponding gastroenterological diseases (Crohn’s disease also presents oral ulceration (OU), mucogingivitis, and a 2–3 times higher risk of PD; Biermer anemia might cause hyperpigmentation by itself), and rheumatologic diseases (lupus induces OU, honeycomb plaques, keratotic plaques, angular cheilitis, buccal petechial lesions, and PD). In more than half of the patients, associated vitiligo involves depigmentation of oral mucosa at different levels (palatal, gingival, alveolar, buccal mucosa, and lips). Celiac disease may manifest xerostomia, dry lips, OU, sialadenitis, recurrent aphthous stomatitis and dental enamel defects in children, a higher prevalence of caries and dentin sensitivity, and gingival bleeding. Oral pigmented lesions might provide a useful index of suspicion for AD in apparently healthy individuals, and thus an adrenocorticotropic hormone (ACTH) stimulation is useful. The spectrum of autoimmune AD comorbidities massively complicates the overall picture of oral manifestations.

The effect of a non‐tobacco‐based nicotine pouch on mucosal lesions caused by Swedish smokeless tobacco (snus)

Oral mucosal lesions are commonly found in Swedish smokeless tobacco (snus) users where the pouch is placed. These lesions are reversible, that is, clinical and histological tissue changes return to normal following cessation. However, the exact mechanisms behind these changes are unknown. The main aim of this study was to investigate how snus‐like non‐tobacco‐based nicotine pouches affect the oral mucosa and the severity of pre‐existing lesions. Sixty regular users of Swedish smokeless tobacco were encouraged to substitute their snus with non‐tobacco‐based nicotine pouch products during a 6‐week period. Meanwhile, oral mucosal lesions were assessed using a four‐degree scale. Over time, a reduction of pre‐existing mucosal lesions was observed between baseline and the final visit. In a second part, the effect of exposure to regular snus on the production of 48 different cytokines in peripheral blood mononuclear cells was compared in vitro with that resulting from exposure to the non‐tobacco‐based nicotine products. Results showed significantly increased production of proinflammatory cytokines in cells exposed to regular snus compared to untreated or cells exposed to the non‐tobacco‐based nicotine products. This may be related to the improved clinical appearance of the oral mucosa in the participants that used the non‐tobacco‐based nicotine test pouches.

Unusual Extensive Physiologic Pigmentation of the Tongue: A Case Report

The deposition of colored endogenous or exogenous substances in the tissues of the tongue may result in pigmented lesions of the lingual mucosa. The accurate identification of the underlying condition can be difficult to achieve and relies mainly on patient history and clinical and histological evaluation. We present the case of a 30-year-old male referred to our hospital with a chief complaint of extensive pigmentation of the lingual dorsum. A diagnosis of physiologic pigmentation based on clinical and histological findings was made. Since some life-threatening diseases may present solely as pigmented lesions of the tongue, an early diagnosis is of utmost importance.

Normal Skin Findings and Cultural Practices in Pediatric Patients with Skin of Color

The understanding of melanocytes is fundamental to the study of dermatology. These dendritic cells underly the most feared primary cutaneous malignancy, fuel escalating progress in immunotherapy strategies, and invariably underlie entire socioeconomic constructs consciously or unconsciously based on skin tone. Various ethno-genotypes combine with increasing frequency over time, increasing the diversity of skin types that may present with dermatologic diagnoses. Understanding the biology of a variety of skin tones and ethnic practices congruent with distribution of skin tone is invaluable to any physician who wishes to practice efficient and expert care, especially to pediatric patients of this category.

Effects of Removal Conditions on Mercury Amount Remaining in the Oral Cavity and inside Drainage System after Removing Dental Amalgams

Mercury is produced and drained into the environment by removing dental amalgams, which may cause mercury pollution. This study aimed to clarify the mercury amount remaining in the oral cavity and inside the drain system after removal. The effects of the removal conditions and differences in drainage systems were also investigated. Dental amalgams filled in the tooth and placed in a phantom head were removed using an air turbine under several conditions (two removal methods, absence of cooling water, and intraoral suction). Then, the oral cavity was rinsed with 100 mL of water (oral rinse water), and 500 mL of water was suctioned to wash the inside of the drainage system (system rinse water). Both water samples were collected in two ways (amalgam separator and gas-liquid separator), and their mercury amounts were measured. It was found that the amount of mercury left in the oral cavity and drainage system after dental amalgams removal could be reduced when the amalgams were removed by being cut into fragments as well as using cooling water and intraoral suction. In addition, using amalgam separators can significantly reduce the amount of mercury in the discharge water and prevent the draining of mercury into the environment.

Mucosal Melanoma: Pathological Evolution, Pathway Dependency and Targeted Therapy

Mucosal melanoma (MM) is a rare melanoma subtype that originates from melanocytes within sun-protected mucous membranes. Compared with cutaneous melanoma (CM), MM has worse prognosis and lacks effective treatment options. Moreover, the endogenous or exogenous risk factors that influence mucosal melanocyte transformation, as well as the identity of MM precursor lesions, are ambiguous. Consequently, there remains a lack of molecular markers that can be used for early diagnosis, and therefore better management, of MM. In this review, we first summarize the main functions of mucosal melanocytes. Then, using oral mucosal melanoma (OMM) as a model, we discuss the distinct pathologic stages from benign mucosal melanocytes to metastatic MM, mapping the possible evolutionary trajectories that correspond to MM initiation and progression. We highlight key areas of ambiguity during the genetic evolution of MM from its benign lesions, and the resolution of which could aid in the discovery of new biomarkers for MM detection and diagnosis. We outline the key pathways that are altered in MM, including the MAPK pathway, the PI3K/AKT pathway, cell cycle regulation, telomere maintenance, and the RNA maturation process, and discuss targeted therapy strategies for MM currently in use or under investigation.

Hyperspectral imaging as a diagnostic tool to differentiate between amalgam tattoos and other dark pigmented intraoral lesions

The goal of this project is to identify any in-depth benefits and drawbacks in the diagnosis of amalgam tattoos and other pigmented intraoral lesions using hyperspectral imagery collected from amalgam tattoos, benign, and malignant melanocytic neoplasms. Software solutions capable of classifying pigmented lesions of the skin already exist, but conventional red, green and blue images may be reaching an upper limit in their performance. Emerging technologies, such as hyperspectral imaging (HSI) utilize more than a hundred, continuous data channels, while also collecting data in the infrared. A total of 18 paraffin-embedded human tissue specimens of dark pigmented intraoral lesions (including the lip) were analyzed using visible and near-infrared (VIS-NIR) hyperspectral imagery obtained from HE-stained histopathological slides. Transmittance data were collected between 450 and 900 nm using a snapshot camera mounted to a microscope with a halogen light source. VIS-NIR spectra collected from different specimens, such as melanocytic cells and other tissues (eg, epithelium), produced distinct and diagnostic spectra that were used to identify these materials in several regions of interest, making it possible to distinguish between intraoral amalgam tattoos (intramucosal metallic foreign bodies) and melanocytic lesions of the intraoral mucosa and the lip (each with P < .01 using the independent t test). HSI is presented as a diagnostic tool for the rapidly growing field of digital pathology. In this preliminary study, amalgam tattoos were reliably differentiated from melanocytic lesions of the oral cavity and the lip.

Proliferative Verrucous Leukoplakia: An Expert Consensus Guideline for Standardized Assessment and Reporting

The many diverse terms used to describe the wide spectrum of changes seen in proliferative verrucous leukoplakia (PVL) have resulted in disparate clinical management. The objective of this study was to produce an expert consensus guideline for standardized assessment and reporting by pathologists diagnosing PVL related lesions. 299 biopsies from 84 PVL patients from six institutions were selected from patients who had multifocal oral leukoplakic lesions identified over several years (a minimum follow-up period of 36 months). The lesions demonstrated the spectrum of histologic features described in PVL, and in some cases, patients developed oral cavity squamous cell carcinoma (SCC). An expert working group of oral and maxillofacial and head and neck pathologists reviewed microscopic features in a rigorous fashion, in combination with review of clinical photographs when available. The working group then selected 43 single slide biopsy cases for whole slide digital imaging (WSI) review by members of the consensus conference. The digital images were then reviewed in two surveys separated by a washout period of at least 90 days. Five non-PVL histologic mimics were included as controls. Cases were re-evaluated during a consensus conference with 19 members reporting on the cases. The best inter-observer diagnostic agreement relative to PVL lesions were classified as "corrugated ortho(para)hyperkeratotic lesion, not reactive" and "SCC" (chi-square p = 0.015). There was less than moderate agreement (kappa < 0.60) for lesions in the "Bulky hyperkeratotic epithelial proliferation, not reactive" category. There was ≥ moderate agreement (> 0.41 kappa) for 35 of 48 cases. This expert consensus guideline has been developed with support and endorsement from the leadership of the American Academy of Oral and Maxillofacial Pathology and the North American Society of Head and Neck Pathologists to recommend the use of standardized histopathologic criteria and descriptive terminology to indicate three categories of lesions within PVL: (1) "corrugated ortho(para)hyperkeratotic lesion, not reactive;" (2) "bulky hyperkeratotic epithelial proliferation, not reactive;" and (3) "suspicious for," or "squamous cell carcinoma." Classification of PVL lesions based on a combination of clinical findings and these histologic descriptive categories is encouraged in order to standardize reporting, aid in future research and potentially guide clinical management.

Oral adverse effects: drug-induced tongue disorders

Objectives

Due to a worldwide increase in drug consumption, oral healthcare professionals are frequently confronted with patients using one or more drugs. A large number of drugs can be accompanied with adverse drug reactions in the orofacial region, amongst others of the tongue. This paper aims to give an overview of drugs that are known to be accompanied with tongue disorders.

Materials and methods

The national drug information database for Dutch pharmacists, composed of scientific drug information, guidelines and summaries of product characteristics, was analysed for drug‐induced tongue disorders. “MedDRA classification” and “Anatomical Therapeutic Chemical codes” were used to categorize the disorders.

Results

The database comprises of 1645 drugs of which 121 (7.4%) are documented to be accompanied with tongue disorders as an adverse effect. Drug‐induced tongue disorders are predominantly observed in the following drug categories: “nervous systems,” “anti‐infectives for systemic use” and “alimentary tract and metabolism”. The most common drug‐induced tongue disorders are glossitis, tongue oedema, tongue discoloration and burning tongue.

Conclusion

Healthcare professionals are frequently confronted with drugs that can cause tongue disorders. The overview of drugs reported in this article supports clinicians in their awareness, diagnosis and treatment of drug‐induced tongue disorders.

Pigmented Lesions

Oral pigmented lesions have a wide range of clinical presentations, some of which correlate with cutaneous pigmented lesions. This article highlights these correlates and underscores important differences that can potentially have clinical impact. Moreover, given a nonspecific presentation of an oral pigmented lesion, the article provides a reference to aid clinicians with differential diagnoses based on clinical features. This article is an overview of pigmented lesions of the oral cavity, including localized reactive pigmented lesions, neoplastic pigmented lesions, and pigmented lesions as sequelae of a systemic disease.

Oral manifestations in a patient with a history of asymptomatic COVID-19: Case report

The pandemic situation has led to public health measures that have forced patients with and without the SARS-CoV-2 virus to remain isolated and take steps to prevent the spread. Many of these patients have been unable to attend the control of medical-dental services, which in many cases complicates their situation. This study reports on the oral manifestations of an asymptomatic COVID-19 patient treated interdisciplinary by teleconsultation due to the sudden appearance of lesions in the oral mucosa. Lesions are diagnosed, therapeutic measures are taken, and improvement is shown. This case shows that the problems that arise in the oral mucosa in patients with suspected or confirmed SARS-CoV-2 infection can be monitored through interdisciplinary teleconsultation during the pandemic with the support of information technology currently available worldwide. It also decreases the risk of transmission of SARS-Cov-2 between patients and health professionals.