Pathology · patient case question
The panoramic radiograph shows a small, dense, irregular radiopacity in the soft tissue overlying the alveolus adjacent to #19. What does this most likely represent?
Patient case: Bronzed Skin and Darkened Gingiva
Patient: 45-year-old female
Chief Complaint: “I’ve been exhausted for months and my gums look darker than they used to.”
Background: Progressive fatigue, 12 lb unintentional weight loss, lightheadedness on standing, strong craving for salty food. No formal medical diagnosis; has not seen a physician in 4 years.
Medications: None
Vital Signs: BP 92/58 mmHg · HR 96 bpm · RR 16 · T 98.4°F
Findings: Diffuse bronze pigmentation of the skin, including areas never exposed to sun. Patchy brown macular pigmentation of the buccal mucosa and attached gingiva. Separately, a discrete 4 mm blue-gray macule in the left mandibular attached gingiva adjacent to a large restoration in #19. Panoramic radiograph obtained.
Show answer and explanation
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.