Bronzed Skin and Darkened Gingiva

Correct answer: B. Primary adrenal insufficiency (Addison disease)

• A. Incorrect. Cushing syndrome is cortisol excess. It produces central obesity, moon facies, a buffalo hump, striae, and hypertension — not hypotension, and not diffuse hyperpigmentation (except in the specific setting of ectopic ACTH).
• B. Correct. Destruction of the adrenal cortex removes cortisol’s negative feedback, so pituitary POMC output rises. α-MSH is cleaved from that same precursor as ACTH, and it drives melanocytes in skin and oral mucosa. The result is the classic triad seen here: generalized bronzing including non-sun-exposed skin, diffuse patchy oral pigmentation, and hypotension with salt craving from mineralocorticoid loss.
• C. Incorrect. Peutz-Jeghers produces discrete perioral and mucosal melanotic macules with intestinal hamartomatous polyps. The macules are focal and present from childhood; there is no systemic bronzing, hypotension, or salt craving.
• D. Incorrect. Graves disease causes heat intolerance, weight loss with increased appetite, tachycardia, tremor, and exophthalmos. Pretibial myxedema is localized, not a generalized bronzing, and blood pressure is typically elevated with a wide pulse pressure.

Note: Anesthetic relevance: an undiagnosed Addisonian patient is at risk of adrenal crisis under the stress of dental treatment. Defer elective care and refer for endocrine evaluation.

Correct answer: D. Amalgam tattoo

• A. Incorrect. A sialolith forms within a salivary duct or gland — most commonly the submandibular duct — and would be seen in the floor of the mouth or gland region, not in the attached gingiva beside a restored molar.
• B. Incorrect. A phlebolith is a calcified thrombus within a vascular malformation. It typically appears as multiple small round radiopacities with concentric “target” laminations, usually in the cheek or masseteric region.
• C. Incorrect. A peripheral osteoma is a well-defined bony outgrowth continuous with the cortex of the jaw, with a uniform trabecular or dense pattern. It is a bone lesion, not a scattered soft-tissue radiopacity.
• D. Correct. Amalgam particles driven into soft tissue during restoration placement or extraction appear as small, dense, irregularly shaped radiopacities that do not conform to any anatomic structure. Its position adjacent to the large restoration in #19 fits perfectly.

Correct answer: C. Fine black granular material along collagen bundles with a foreign-body reaction

• A. Incorrect. That describes a blue nevus. It is a genuine consideration for a blue-gray oral macule, but the associated radiopacity next to a large amalgam restoration makes tattoo far more likely here.
• B. Incorrect. That describes a varix, which appears as a soft, compressible blue-purple papule that blanches on diascopy, most often on the ventral tongue or lower lip. It would not be radiopaque.
• C. Correct. This is an amalgam tattoo. Metallic particles deposit along collagen fibers, basement membranes, and vessel walls, and larger fragments provoke a chronic foreign-body giant cell reaction. It is the diagnosis that matches both the clinical blue-gray color and the radiopacity seen on the panoramic.
• D. Incorrect. That describes an oral melanotic macule — a flat brown lesion from increased melanin without melanocytic proliferation. It is brown rather than blue-gray and produces no radiopacity.

Note: Clinical rule: a blue-gray macule with a matching radiopacity needs no biopsy. Biopsy is reserved for pigmented lesions with no radiographic correlate, since melanoma is the lesion you cannot afford to miss.