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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 6  |  Page : 293-296

Pigmented injury in the jugal mucosa

1 Department of Stomatology, Faculty of Health Sciences, Universidade do Vale do Paraíba (UNIVAP), Schools of Dentistry, São Paulo, Brazil
2 Department of Stomatology, Faculty of Health Sciences, Universidade do Vale do Paraíba (UNIVAP), Schools of Dentistry; Laser Therapy and Photobiology Center, Institute of Research and Development, UNIVAP, São Paulo, Brazil

Date of Web Publication20-Dec-2017

Correspondence Address:
Dr. Renata Amadei Nicolau
Av. Shishima Hifumi, 2911, Urbanova, CEP: 12.244-000, São José dos Campos - São Paulo

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_186_17

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The buccal cavity can be affected by lesions with different clinical aspects. The pigmented lesions are distinguished by their various causes and consequently, numerous treatments and prognoses. Exogenous pigmentations, melanocytic nevus, and melanocytic melanoma may present very similar clinical characteristics, which makes diagnosis difficult and compromises treatment. The objective of this study was to report the case of a patient diagnosed with melanoma and surgical indication but who, after careful clinical examination and biopsy, received the final diagnosis of exogenous pigmentation. The ABCDE criterion served as a guide to the distinction between benign and malignant lesions; however, complementary tests are essential to conclusive diagnoses, as in the reported case. Radiographic examination may be useful in the differentiation of pigmentation from metallic material; however, as observed in the present case, the examination is not always conclusive. The biopsy was fundamental to obtain the diagnosis and determine the ideal treatment approach. From the case reported, it was possible to conclude that detailed anamnesis and physical examination were essential to guide clinical management.

Keywords: Melanoma, metal tattoo, pigmentation, pigmented snow

How to cite this article:
Matuda AG, Deco CP, Canettieri AC, Nicolau RA. Pigmented injury in the jugal mucosa. J Int Oral Health 2017;9:293-6

How to cite this URL:
Matuda AG, Deco CP, Canettieri AC, Nicolau RA. Pigmented injury in the jugal mucosa. J Int Oral Health [serial online] 2017 [cited 2022 Jan 26];9:293-6. Available from:

  Introduction Top

The buccal cavity can be affected by numerous lesions with different morphological aspects. Pigmented lesions are distinguished by their various causes and consequently, numerous treatments. Relatively harmless lesions such as an amalgam tattoo or a melanocytic nevus may appear to be clinically very similar to an aggressive melanoma. The clinical similarities among lesions make diagnosis difficult and may delay the initiation of treatment.[1],[2]

Exogenous pigmentations result from the implantation of materials, as fragments of carborundum discs [3] or amalgam,[4] in the buccal mucosa. Endogenous pigmentations are mainly caused by accumulation of melanin. Pigmented melanocytic nevus is a benign lesion that presents clinically as a brownish spot, which makes it a differential diagnosis of melanoma.[1],[5],[6],[7],[8] A precise diagnosis is essential to the success of the treatment.[1],[2]

The objective of this study was to report the case of a patient diagnosed with melanoma, but who, after examination and biopsy, received a final diagnosis of exogenous pigmentation.

  Case Report Top

This case report was authorized by the Human Research Ethics Committee, under CAAE number: 69811317.2.0000.5503. Patient E.M.S.R (female, leukoderma, 65 years old, retired teacher) presented to the dentistry polyclinic with a dark spot inside her mouth. The patient reported a previous medical visit in which she received a diagnosis of melanoma and an indication that the lesion should be surgically removed. Because it is a malignant lesion whose removal requires extensive surgical margins, the patient sought a second opinion at UNIVAP. In the intraoral clinical examination, a brownish spot on the right jugal mucosa, close to the labial retrocommissure, was observed [Figure 1]. The staining was heterogeneous, and in the middle of the brown spot, there were three black spots regularly distributed among the lesion. The largest stain was 10 mm × 8 mm at its largest diameter and had a smooth surface with irregular and undefined contours. There were three more satellite spots previously located in relation to the larger spot, one brownish in color and the other two blackish, but all with heterogeneous staining patterns and diameters of approximately 2 mm each. After the clinical examination, the patient underwent a diascopy test to exclude the hypothesis of a vascular lesion [Figure 2].
Figure 1: Clinical aspect of the lesion

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Figure 2: The diascopy showed to be a pigmented lesion

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Applying the ABCDE criteria [Table 1], the clinical characteristics of the lesion indicated that it could be a melanoma. However, during the intraoral examination, a dental professional observed that the patient presented total metallic crowns in the lower right lower molars and that these crowns were oriented toward the mucosa in which the spots were observed. Palpation revealed a minimal lesion depth. These data led to the hypothesis that the stain previously considered to be melanoma could be simply an exogenous pigmentation. An X-ray of the jugal mucosa was made, but no image compatible with metallic material was obtained. In view of this condition, an excisional biopsy was chosen.
Table 1: Criterion “ABCDE”

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The lesion was removed using an intraoral approach with infiltrative technique under local anesthesia with a 2% mepivacaine hydrochloride anesthetic cartridge. The area to be excised was demarcated [Figure 3], and the soft tissues were incised in the jugal mucosa with a 15C stainless steel scalpel blade. After removal [Figure 4], the lesion was placed in 10% formalin solution for future anatomopathological evaluation.
Figure 3: Demarcation of the area to be excised

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Figure 4: Lesion soon after its removal

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[Figure 5] shows the appearance of the surgical bed immediately after removal of the lesion. The excision site was sutured with 4.0 silk thread using single stitches [Figure 6]. Five days after surgery, the patient returned for evaluation, and the mucosa presented a healthy appearance with no signs of inflammation or infection.
Figure 5: Aspect of the surgical bed after the removal of the lesion

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Figure 6: Suture of the region

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The material was submitted for anatomopathological analysis, and the final diagnosis was exogenous pigmentation. The histological sections [Figure 7]a,[Figure 7]b,[Figure 7]c showed deposition of exogenous brownish or brownish black matter with either fine or coarse granulation, mostly in perivascular regions.
Figure 7: (a-c) Photomicrographs of the biopsied lesion area. Coloration with H and E. Numerical representation - 1: Exogenous material posed in the perivascular region; 2: Mature adipocytes; 3: Congestive vessel; 4: Chronic inflammatory infiltrate; 5: Exogenous material along the basement membrane; 6: Exogenous material of blackish color in lumps; 7: Exogenous material dispersed between collagen fibers; 8: Salivary gland duct

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The diagnostic brought great comfort to the patient. The search for a second opinion allowed her to receive adequate treatment and avoid unnecessary mutilating surgery.

  Discussion Top

Obtaining the patient's medical history is essential for guiding the diagnosis of a pigmented lesion. Physical examination also helps exclude such a hypothesis if amalgam restorations or metallic crowns are present,[1],[2] as in this patient.

Exogenous pigmentation is frequently presented as localized spots on the oral mucosa, of blackish or grayish color due to the presence of metals such as silver, mercury, and tin in dental alloys.[4],[5],[9] The exogenous pigmentation features can be easily confused with pigmented melanocytic nevus and even with a melanoma since both also appear as darkened lesions of similar size that can affect the same regions. The difficulty in clinically differentiating lesions such as these was evident in the case reported, in which the patient almost underwent surgery to remove a melanoma, even without a certain diagnosis.

To differentiate benign lesions from a melanoma, it is recommended to use the evaluation “ABCDE” criteria.[3],[10] In the present case, except for the criterion of evolution, all the others led to the belief that it was a case of melanoma.

Radiographic examination may be very useful in differentiating an endogenous pigmentation from an exogenous pigmentation by metallic material. In the latter case, good contrast radiographs may be able to reveal the metal fragments that appear as radiopaque images. However, the fragments are often very small and able to be detected only by microscopic evaluation,[3],[9] as occurred in the case reported.

The biopsy is necessary and presents urgency when the area affected is that of the palate, which is often the site of melanoma.[4],[5],[7] In the case reported, although the localization was not of high prevalence for melanoma, excisional biopsy was performed quickly because the clinical characteristics of the lesion fit most ABCDE criteria, and the patient already suspected a malignant lesion.

Histopathological cuts of extrinsic pigmentation lesions, such as amalgam tattooing, reveal the presence of exogenous material in the tissue. This material may be viewed as darkened granules, which may be free between connective tissue fibers or within multinucleated giant cells, depending on the type of response elicited. Chronic mild inflammation is common.[3]

In the pigmented melanocytic nevus, accumulation of nevus cells is observed in the basal layer of the epithelium, in the underlying connective tissue or both, which causes the coloration found in the region.[5],[6]

In melanoma, atypical fusiform or epithelioid melanocytes with varying degrees of nuclear pleomorphism are observed. In initial lesions, they are found in regions bordering the epithelium and lamina propria, but with disease evolution, neoplastic cells invade the connective tissue and form nests or strings of pleomorphic cells. In melanocytic melanoma, the cells present small granules of melanin in their interiors, which gives them the darkened characteristic. Invasion may occur in adjacent blood and lymphatic vessels and regions of necrosis and ulceration.[3],[7]

In the present report, an excisional biopsy was performed, and therefore, the diagnostic method was also the treatment since the report confirmed the hypothesis of exogenous pigmentation.

Treatment varies according to the diagnosis. An extrinsic pigmentation does not require any treatment,[5] and removal is indicated just for cosmetic reasons.[4] The treatment of melanocytic nevus is surgical removal and the treatment of melanoma is invasive. Large tumors should be excised with extense surgical margins.[3],[5] Radiotherapy an chemotrerapy [1],[5],[7] candidato be used postoperatively.

In the case described, the biopsy was extremely important for obtaining a conclusive diagnosis. It is necessary to perform diagnoses in a timely manner, considering that among this group of lesions is melanoma, which has a poor prognosis and requires immediate treatment.

  Conclusion Top

The wide variety and frequency of pigmented lesions capable of affecting the oral cavity can make the diagnostic process difficult, as occurred in the present case. Most of the time, only a biopsy will allow for a certain diagnosis. No treatment course should be instituted without a certain diagnosis, at the risk of causing harm to the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lundin K, Schmidt G, Bonde C. Amalgam tattoo mimicking mucosal melanoma: A diagnostic dilemma revisited. Case Rep Dent 2013;2013:787294.  Back to cited text no. 1
Tarakji B, Umair A, Prasad D, Alsakran Altamimi M. Diagnosis of oral pigmentations and malignant transformations. Singapore Dent J 2014;35C:39-46.  Back to cited text no. 2
Neville BW, Damm DD, Allen CM, Bouquot JE. Patologia Oral e Maxilofacial. Rio de Janeiro, Brasil: Guanabara Koogan; 2004.  Back to cited text no. 3
Galleta VC, Dal Vechio AM, Migliari DA, Artico G, Lemos CA Jr. Large amalgam tatoo in the gengival mucosa. An Bras Dermatol 2011;86:1019-21.  Back to cited text no. 4
Kauzman A, Pavone M, Blanas N, Bradley G. Pigmented lesions of the oral cavity: Review, differential diagnosis, and case presentations. J Can Dent Assoc 2004;70:682-3.  Back to cited text no. 5
Pandey P, Chaudhary CP, Ansari AA, Singh R. Intramucosal nevus of buccal mucosa in a male child. BMJ Case Rep; Published online; 2013. [DOI:10.1136/bcr-2013-010191].  Back to cited text no. 6
Lamichhane NS, An J, Liu Q, Zhang W. Primary malignant mucosal melanoma of the upper lip: A case report and review of the literature. BMC Res Notes 2015;8:499.  Back to cited text no. 7
Ali EA, Karrar MA, El-Siddig AA, Zulfu A. Oral malignant melanoma: A rare case with unusual clinical presentation. Pan Afr Med J 2015;22:113.  Back to cited text no. 8
Vera-Sirera B, Risueño-Mata P, Ricart-Vayá JM, Baquero Ruíz de la Hermosa C, Vera-Sempere F. Clinicopathological and immunohistochemical study of oral amalgam pigmentation. Acta Otorrinolaringol Esp 2012;63:376-81.  Back to cited text no. 9
Munde A, Juvekar MV, Karle RR, Wankhede P. Malignant melanoma of the oral cavity: Report of two cases. Contemp Clin Dent 2014;5:227-30.  Back to cited text no. 10
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