International Journal of Applied Dental Sciences 2019; 5(2): 397-402

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2019; 5(2): 397-402 Classification of oral pigmented lesions: A review
© 2019 IJADS
www.oraljournal.com
Received: 09-02-2019
Accepted: 10-03-2019
Dr. Reshna Roy
Dr. Reshna Roy Abstract
Senior Lecturer, Department of
Mouth reflects the health status of an individual. There are various pigmented lesions present widely in
Oral Pathology & Microbiology,
Hazaribagh College of Dental
an around the oral cavity which depicts whether they are benign or malignant. Therefore, classification
Sciences and Hospital, has been made to quantify the size, color, location of the lesion. And also proper management can be
Hazaribagh, Jharkhand, India made depending on the lesion. Dental professionals deal with the lesions pertaining to oral cavity, so
classification made eases their quality of their work and also in treating the patient.

Keywords: Pigmented lesions, endogenous, exogenous, physiological

Introduction
It is said “mouth is mirror of body” because many dermatological lesions have their
manifestation in oral cavity.
There forms a strong link between the skin and oral mucosa: The skin arises by the
juxtaposition of two major embryological elements: the prospective epidermis, which
originates from a surface area of the early gastrula, and the prospective mesoderm, which is
brought into contact with the inner surface of the epidermis during gastrulation .The neural
crest also makes an important contribution to the skin, namely the pigment cells so called as
melanin, although their bulk is small whereas the primitive oral mucosa is lined by ectoderm
and is separated from the gut by the buccopharyngeal membrane [1]. The color of the oral
mucosa is the net result of a number of factors, one of which is pigmentation. The pigments
most commonly contributing to the color of the oral mucosa are melanin and hemoglobin.
Melanin is produced by specialized pigment cells, called melanocytes, situated in the basal
layer of the oral epithelium. Melanocytes arise embryologically from the neural crest ectoderm
and enter the epithelium at about 11 weeks of gestation. In the epithelium they divide and
maintain themselves as a self reproducing population. Melanocytes possess long dendritic
(branching) processes that extend between the keratinocytes, often passing through several
layers of cells. Melanin is synthesized within the melanocytes as small structures called
melanosomes [2]
We know that there are gradations in skin colour i.e During slavery, lighter-skinned African-
Americans were perceived as more intelligent, cooperative, and beautiful than do blacks and
this prevailed in India too and this led to the discriminations between “Blacks & Whites”-------
--Lightly and darkly pigmented individuals have the same number of melanocytes in any given
region of skin or oral mucosa; color differences result from the relative activity of the
melanocytes in producing melanin and from the rate at which melanosomes are broken down
in the keratinocytes. In persons with heavy melanin pigmentation, cells containing melanin
may be seen in the connective tissue. Light-skinned persons rarely show any oral melanin
pigmentation [3].
Human skin pigmentation is a complex trait that evolved as an adaptation to local
environmental conditions. The distribution of human skin colour is highly correlated with the
Correspondence intensity of incident ultraviolet radiation. Although pigmentation of the skin is 0influenced by
Dr. Reshna Roy pigments such as carotene, reduced haemoglobin and oxyhaemoglobin, the main determinant
Senior Lecturer, Department of is however the pigment melanin. Melanin is a complex mixture of biopolymers, whose
Oral Pathology & Microbiology, synthesis takes place within the melanosomes, specialized lysosomal organelles typical of
Hazaribagh College of Dental
Sciences and Hospital, melanocytes [4].
Hazaribagh, Jharkhand, India Oral Pigmentations generally occur as diffuse lesions throughout the oral cavity or as an
~1~
isolated focal lesion. The
word “Pigment” is
derived from the Latin
word meaning

~2~
International Journal of Applied Dental Sciences

“Color or Coloring” and so pigmented lesions of oral mucosa prevalence rate as 0.26%.
may be applied to a wide range of entities caused by the c) Depigmentation: includes vitiligo which is a chronic
accumulations of one or more pigments and featuring a stigmatizing disease, already known for millennia, which
change in color of the tissues. Pigmented lesions may mainly affects melanocytes from epidermis basal layer,
represent a localized anomaly of limited significance or the leading to the development of hypochromic and achromic
presentation of potentially life threatening multisystem patches. Its estimated prevalence is 0.5% worldwide [11].
disease [2] d) Hemoglobin or iron associated pigmentation: such as
Oral mucosa is deeply colored when compared to skin which ecchymosis is a lesion which will assume a brown
denotes that discoloration of the oral mucosa by pigment coloration after the hemoglobin degraded to hemosiderin.
occurs with many different conditions, which may be When multiple brown macules or swellings are observed
otherwise totally unrelated in many other respects. The color and ecchymosis is included in the differential diagnosis, a
of oral mucosa depends upon the epithelial thickness, the hemorrhagic diathesis or coagulation disorder should be
keratin status, the vascularity, and the density of the considered, certain patients taking anti-coagulant drugs
underlying fibrous tissue/hard tissue. Lesions like erosions may be present with oral ecchymosis. Capillary
(shallow ulcers) will lead to epithelial thinning and the red hemorrhages such as purpura or petechiae will appear red
color of the vascularized tissues. Color reflects the clinical initially and turn brown in a few days once the
state of the mucosa; inflamed tissues are red, because of the extravasated red cells have lysed and have degraded to
increase in number and dilation of blood vessels, whereas hemosiderin. Hemochromatosis is a chronic, progressive
normal healthy tissues are pale pink. This coloration is the net disease that is characterized by excessive iron deposition
result of many factors, one of which is pigmentation and so in the liver and the other organs and the tissues and this
oral pigmentation is likely to have a multifactorial etiology3. cutaneous pigmenatation is seen in and over 90% of all
Oral pigmentations can be endogeneous, exogeneous, affected patients [12].
depigmentation or hemoglobin and iron-associated e) Idiopathic: Pigmentation such as Laugier- Hunziker
pigmentation or idiopathic. pigmentation (Laugier- Hunziker Syndrome) was initially
a) Endogeneous pigmentation: includes oral melanotic described as an acquired, idiopathic, macular
macule which is a flat, brown mucosal discoloration hyperpigmentation of the oral mucosal tissues
produced by a focal increase in the number of specifically involving the lips and buccal mucosa. Upto
melanocytes and it accounts for 85% of all solitary 60% of affected patients also may have usually are in the
melanocytic lesions diagnosed. Oral melanoacanthoma is form of longitudinal melanotic streaks and without any
a rare, ill-defined macular or popular like lesions with evidence of dystrophic change [12]
only approximately fewer than 100 cases reported. Many oral pigmentations have widespread manifestations and
Melanomas are common cancers arising from the is quite variable ranging from focal, multifocal, or diffuse or
pigment cells of the skin and it accounts for 4%-6% per blue, purple, brown, gray, or black or macular or tumefactive.
annum. Certain drugs also induces oral pigmentation and The precipitating factors affecting melanogenesis can be
melanosis and it has been estimated that 10-20% of all sunlight, drugs,hormones,genetic constitution or racial factors
[6]
cases of acquired melanocytic pigmentation may be drug Here the oral pathologist plays a very important role in
induced5. Smokers melanosis condition may be due to the detecting such diseases at the very initial stage.
physical effect of tobacco smoke on the oral tissues by The incidence of Peutz-Jeghers syndrome reported is 1, 087
heat and/or the direct effect of nicotine stimulating people in USA and 4260 people in INDIA. Furthermore oral
melanocytes located along the basal cells of the melanin pigmentation reported is with 30% and 98% among
epithelium to produce more melanosomes, thus resulting Asians; Arsenic consumption reports (13 million people) in
in increased deposition of melanin and the prevalence USA and 42.7 million in INDIA. Patients with Smoker’s
ranges from 21-90% [6]. Melasma is an acquired melanosis is found to be 4.1% in India and lastly 0.5% is
increased pigmentation of the skin,a symmetric reported with oral melanoma in India.
hypermelanosis, characterized by irregular light to gray Oral pigmentation may be physiologic or pathologic. 13
brown macules and the prevalence rate suggests between Pigmentations in the oral cavity vary from color to color and
melasma and pregnancy since 50-70% of pregnant also in shape and size. They may spread as diffusely or
women seem to develop melasma whereas women remain consolidated in one particular site. They can occur
receiving oral contraceptives seem to develop melasma in either under normal conditions.
about 38% of the cases [7]. Genetically associated
pigmentation such as Addison’s Disease exibits brown Classification
macular pigmentation of local or diffuse quality and Oral pigmentation has been associated with variety of lesions
affects 110 to 144 of every 1 million people in developed and conditions. Oral pigmentation is a relatively common
countries [8]. Peutz-Jeghers syndrome (PJS) is an condition that may involve any part of the oral cavity. A
autosomal dominant syndrome characterized by multiple dental professional can encounter a number of pigmented
hamartomatous polyps with an estimated prevalence of conditions in the oral cavity in day to day practice. It is
1:8000 to 1:200,000 births. Males and females are therefore important to differentiate between normal and
equally affected [9]. Café au lait spots are macules varying pathological pigmentations. Broadly, pigmentation is
from light brown to dark brown with smooth or irregular classified into endogenous, exogenous, and idiopathic and
borders [10]. heme related pigmentations. However various classifications
b) Exogenous pigmentation: such as amalgam tattoo or any have been suggested in the literature to elaborate as well as
heavy metal deposits is an iatrogenic entity defined as a simplify their diagnosis [14].
bluish, black or grey lesion of the oral mucous membrane
caused by accidental implantation of silver amalgam into Classification Proposed By Faizan Alawi [12]:
the tissue during tooth restoration or extraction with This classification system groups the orofacial pigmentations
International Journal of Applied Dental Sciences
in to 4 broad categories 3. Hemochromatosis 2. Minocycline pituitary gland
including endogenous and 3. Chloroquine f) Pregnancy and female
exogenous pigmentation, D) Exogenous Pigmentation 4. Cis platinium sex hormones
idiopathic and heme- 1. Amalgam Tattoos 5. Cyclophosphamide g) Von-Recklinghausen’s
associated pigmentation. It 2. Graphite Tattoos disease(neurofibromatos
provides an easy and 3. Ornamental Tattoos D) Syndromes is)
simplified reference point 4. Medicinal Metal- Associated With
for the study of the induced Pigmentation And Perioral Pigmentation: b) Bilirubin
pigmented lesions. 5. Drug-induced 1. Peutz-Jeghers a) Jaundice
A) Endogenous Pigmentation Syndrome
Pigmentation: 6. Hairy Tongue 2. Laugier-Hunziker 3. Iron
1. Focal Melanocytic Syndrome c) Haemochromatosis
Pigmentation According To Thibodeau 3. Addison’s Disease
a) Freckle/Ephelis Ea et al15: 4. Albright Syndrome B) Exogenous Pigmentation:
b) Oral/Labial Melanotic This system of classification 5. Neurofibromatosis 1. Systemically introduced
Macule is grouped into five sub- metallic substances
c) Oral Melanoacanthoma categories which includes E) Miscellaneous Lesions: a) Mercury
d) Melanocytic Nevus endogenous, exogenous, 1. Varicosities b) Bismuth
e) Malignant Melanoma drug- related, oral & 2. Hemangiomas c) Lead
perioral and miscellaneous. 3. Black Hairy Tongue d) Silver
2. Multifocal/Diffuse This is an elaborate form of 4. Pigmented Fibroma e) Mercury
Pigmentation classification. 5. Nevus f) Gold
a) Physiologic g) Arsenic
Pigmentation A) Endogenous According To Pramod
b) Drug-induced Pigmentation: John Classification16: 2. Locally introduced
Melanosis 1. Melanin This form of classification pigments
c) Smoker’s Melanosis 2. Blood and bile pigments is basically formed of two a) Amalgam Tattoo
d) Post-inflammatory 3. Carotene broad categories such as b) Graphite
Hyperpigmentation 4. Lipofuscin endogenous and
e) Melasma(Chloasma) exogeneous pigmentations. 3. Miscellaneous Conditions
B) Exogenous It provides an easy access a) Black Hairy Tongue
3. Melanosis Associated Pigmentation: to understand from this b) Carotenaemia
With Systemic Or 1. Accidental point of reference. c) Stains from tobacco etc.
Genetic Disease impregnation
a) Hypoadrenocorticism 2. Iatrogenic impregnation A) Endogenous According to Amit Parate
(Adrenal 3. Increased exogenous Pigmentation: et al17:
Insufficiency/Addison’ deposition a) Melanin This form of classification
s Disease) a) Normal racial variation includes provides a
b) Cushing’s C) Drug Related b) Addison’s disease descriptive discussion about
Syndrome/Cushing’s Pigmented Lesions c) Peutz-Jeghers each lesion and thus
Disease 1. Naproxen Syndrome provides an enhance idea
c) Hyperthyroidism d) Albright’s Syndrome regarding each lesion in
(Graves’ Disease) e) Hyperfunction of the toto.
d) Primary Biliary
Cirrhosis A) According To Color mo
e) Vitamin B12 sis/
(Cobalamin) 1. Color: mel
Deficiency a) Blue/Purple ano
f) Peutz-Jeghers b) Brown ma/
Syndrome c) Gray Black dru
g) Café au Lait g
Pigmentation 2. Focal: ind
h) HIV/AIDS-Associated a) Varix/ Hemangioma uce
Melanosis b) Melanotic Macule d/h
/Nevus / Melanoma airy
B) Idiopathic c) Amalgam ton
Pigmentation Tattoo/Graphite gue
Laugier-Hunziker tattoo/nevus/melanom /pet
Pigmentation a ech
iae
C) Hemoglobin And Iron- 3. Diffuse: c) Amalgam Tattoo/hairy
Associated a) Hemangioma tongue
Pigmentation: b) Ec
1. Ecchymosis c 4. Multifocal:
2. Purpura/Petechiae h a) Kaposi
y Sarcoma/Hereditary
International Journal of Applied Dental Sciences
hemorrhagic i) Metal Ingestion u t
telangiectasia s t
b) Hereditary B) Second Classification H o
hemorrhagic 1. Diffuse and bilateral: e o
telangiectasia Early m
c) Physiologic Onset a B
pigmentation - t l
d) Neurofibromatosis Physi o u
e) Lichen Planus ologi m e
f) Addison’s disease cal a
g) Drug induced pigm Blue-gray: N
h) Peutz- Jeghers entati e
Syndrome on Amalgam Tattoo v
Peutz O u
– t s
Jeghe h Oral
rs e mela
syndr r notic
ome macu
Predominan f le
tly adults o Pigm
onset- r ented
Addisons’s e nevu
disease i s
Kaposi g Mela
sarcoma n noac
Heavy metal pigmentation antho
No systemic signs b ma
and symptoms – o Mela
Smoker’s Melanosis d noma
Drug-induced y
pigmentation C) Endogeneous
Post inflammatory t Pigmentation
pigmentation a

Pigment Colour
2. Focal Hemoglobin Blue, Purple, Red Varix, Hemangioma, Kaposi’s sar
Red blue purple blanching: Hemosiderin Brown Ecchymosis, Petechiae
Hemangioma Melanin Brown, Black, Gray Melanotic mac
V
a According To Sr Prabhu et 11. Pigmentation associated
r al. [18]: with systemic disease
i Classification of Pigmented for example Addison’s
x Lesions of the Oral Mucosa Disease, Peutz-Jeghers
N based on the source or origin syndrome, Albright’s
o of Pigment: Syndrome, HIV/AIDS
n
- Lesions caused by Lesions produced by
endogeneous exogeneous pigmentation:
B pigmentation: 1. Amalgam Tattoo (Focal
l 1. Physiological, racial Agyrosis)
a pigmentation 2. Heavy-metal
n (melanoplakia) pigmentation.
c 2. Ephelis (freckle) 3. Tattoos-cultural and
h 3. Oral melanotic macule social.
i 4. Smoking-associated
n melanosis Classification of Pigmented
g 5. Lentigo Lesions of the oral mucosa
: 6. Naevus Based on Clinical
7. Melanoma Presentation of Lesions
T 8. Neuroectodermal
h tumour of infancy Localized
r 9. Drug-induced 1. Amalgam and other
o pigmentation tattoos
m 10. Drug-induced 2. Ephelis(freckle)
b pigmentation. 3. Melanotic macule
International Journal of Applied Dental Sciences
4. Naevus Nevus, an elaborate form of
5. Malignant melanoma
Amalgam Tattoo classification [15]
b) Multifocal: Kaposi Another author named
Generalized
sarcoma, Hereditary JOHN et al. classified is
1. Genetic
hemorrhagic basically formed of two
a) Racial(physiological)
telangiectasia, broad categories such as
b) Peutz-Jeghers syndrome
endogenous and exogeneous
Physiologic pigmentations. It provides an
2. Drug-Related
easy access to understand
a) Smoking
pigmentation, from this point of reference
b) Heavy metals for [16]
Neurofibromatosis, .
example
Lichen Planus PARATE et al in his studies
arsenic,bismuth,lead
formed a classification
c) Anti-malarials includes provides a
d) Tetracyclines 2. Diffuse: Hemangioma,
Ecchymosis, hairy tongue descriptive discussion about
e) ACTH each lesion and thus
f) Zidovudine provides an enhance idea
g) Clofamazine D) According To
Syndromes Associated regarding each lesion in
h) Methyldopa toto.17
i) Busulphan 1. Generalized: Addisons
Syndrome, Nelsons By this author SR PRABHU
j) Menthol et al, Classification of
k) Contraceptive pills Syndrome, Albright
Pigmented Lesions of the
l) Endocrine Syndrome
Oral Mucosa was based on
m) Addisons disease 2. Localized: Peutz-
the source or origin of
(hypoarenocorticism) Jeghers Syndrome,
Pigment [18]
n) Albright’s syndrome Laugier-Hunziker
o) Pregnancy Syndrome
p) Other
q) Incontenentia pigmenti Discussion
r) Generalized Pigmented lesions are those
neurofibromatosis lesions which are either
s) Wilson’s disease endogenous or exogenous in
t) Gaucher’s disease origin. It is multifactorial in
u) HIV disease nature. Pigmented lesions
either present orally or in
Compiling all the above general which occurs due to
classifications into deposition of melanocytes
consideration, we have in the tissues. Solitary
proposed our own melanocytic pigmented
classification. This lesions on the oral mucosa
classification is are infrequent, representing
only 0.9% of cases
chiefly grouped broadly
evaluated in oral and
into 4 categories such as Angiosarcoma, maxillofacial pathology
colour, shape & size, Amalgam Tattoo services. Most affected
location or site and 5. RED: Hemorrhage individuals are in their 30s
syndromes associated. telangiectasia
or 40s [20]
According to Alawi et al,
A) According To Color: B) According to Shape &
this classification system
1. BROWN: Ecchymosis, Size
groups the orofacial
Petechiae, Varix, 1. SMALL: Freckle, Oral
pigmentations in to 4 broad
Hemorrhage, Melanotic Macule, categories including
Mucocele, Melanocytic Nevus,
endogenous and exogenous
Hemochromatosis. Petechiae pigmentation, idiopathic and
2. BLACK: Melanotic 2. MEDIUM: Amalgam
heme-associated
Macule, Nevus, Tattoo, Graphite pigmentation. It provides an
Melanoma, Basilar Tattoo, Lichen Planus.
easy and simplified
melanoma. 3. LARGE: Melasma, reference point for the study
3. GRAY: Foreign Body Post-inflammatory
Tattoo of the pigmented lesions [12].
Pigmentation
THIBODEAU EA et al
4. BLUE/PURPLE:
stated that classification is
C) According to
grouped into five sub-
Kaposi Location/Site categories which includes
1. Focal: endogenous, exogenous,
Sarcoma, a) Unifocal: Hemangioma, drug-related, oral & perioral
Melanotic Macule, and miscellaneous. This is
International Journal of Applied Dental Sciences
These above mentioned 2009; 1(1):38- 45 14. Sabrinath B,
authors shows the various 3. Ham K, Sarfati J, Sivapathasundharam
locations or sizes Wieland C. The B, Ghosh G, Dhivya.
concerned with that of the Revised & Expanded National Academy of
various lesions. But, in our Answers Book; Master Dentistry. Indian J
study we have compiled Books, 2000 Dent Sci. 2009;
all the above 4. Lopez S, Alonso S. 1(1):38-45.
classifications into Evolution of Skin 15. Thibodeau. Durgesh N
consideration, we have Pigmentation Bailoor, Nagesh KS.
proposed our own Differences in Fundamentals of Oral
classification. This Humans. ELS John Medicine and
classification is chiefly Wiley & Sons 2014, 1- Radiology.1st ed.
grouped broadly into 4 8 Jitender P Vij, 2005
categories such as colour, 5. Whiteman D, Green 16. Pramod John R.
shape & size, location or A. Epidemiology of Essentials of Oral
site and syndromes Malignant Melanoma. Medicine.1st ed.
associated. Each lesion is Skin Cancer – A Jitender P Vij, 1998
sub-divided into small, World-Wide
medium and large. Also Perspective, 2011, 13- 17. Amit Parate. Anil
the lesions are divided into 26 Govindrao Ghom Textbook of
unifocal, multifocal and 6. Nadeem M, Shafique Oral
diffuse locations. R, Yaldram A, López Medicine. 1 st ed. Jaypee
This classification R. Intraoral Brothers Medical Publishers,
proposes the entire entities distribution of oral 2005
at one particular place melanosis and 18. Prabhu SR. Textbook Of
which eases our cigarette smoking in a Oral Medicine.1st ed.Oxford
difficulties in studying the Pakistan population. University Press, 2004
classification. Int J Dent clin. 2011; 19. Pennacchiotti G, Oviedo
3(1):25-8 C, Ortega-Pinto A. Solitary
Conclusion 7. Tzouveka E. pigmented lesions in oral
The diagnosis of oral Epidemiology and mucosa in Latin American
pigmentation is difficult. Risk Factors of children: Case series report.
Thus, biopsy is indeed Melasma. J Pigmnt Pediatr Dermatol. 2018;
essential for each and Dis 2014; 1(2):1-3 00:1-4.
every lesion, so that 8. Betterle C, Morlin L. 20. Buchner A, Merrell PW,
histopathological Autoimmune Carpenter WM. Relative
evaluation confirms the Addison’s disease. J frequency of solitary
diagnosis. Thus, Adr Insuff and Add melanocytic lesions of the
classification is made to Dis. 2011, 161-72 oral
differentiate the various 9. Attard T. Peutz- mucosa. J Oral Pathol Med.
lesions according to shape, Jeghers Syndrome. 2004; 33(9):550-7
size, color and location of Peutz-Jeghers
the particular lesion. This Syndrome: Overview,
classification in lesions Genetics,
would rather provide Epidemiology 2006: 1-
benefit for the evaluation, 13
prognosis and 10. Rathnayake D,
management in treating Sinclair R. Disorders
the lesion. of pigmentation.J
Derm 2014, 29-36
References 11. Robert L. Vitiligo.
1. McGrath JA, Eady Lippincott Williams &
RAJ, Pope FM. Wilkins 2016, 1-9
Anatomy and 12. Greenberg, Glick,
Organization of Ship. Burket’s Oral
Human Skin. Practical Medicine.11th ed, BC
Approach Series. Decker Inc, 2008
Oxford: Oxford 13. Nosotti MG, Vigano
University Press, L, Casu C. Oral
1993 mucosa pigmented
2. Sabrinath B, lesions: an overview
Sivapathasundharam of the recent literature
B, Gaurav Ghosh, and 3 case reports.
Dhivya. Pigmentation. Dentist Case Rep.
Indian J Dent Adv. 2018; 2(3):40-43