Pathology · patient case question
What is the diagnosis of the gingival pigmentation?
Patient case: Rampant interproximal caries in a smoker who chews mints
Patient: Male, 34 years old
Chief Complaint: “I keep getting cavities between my teeth even though I brush.”
Background: Smokes half a pack a day. Reports brushing twice daily with a fluoride toothpaste. Uses sugar-containing breath mints continuously through the working day to mask the smell of smoke.
Current Findings: Carious lesions on virtually every interproximal surface. Diffuse brown-black pigmentation distributed symmetrically along the attached gingiva of both arches, unchanged for as long as he can remember.
Show answer and explanation
Correct answer: B. Physiological (racial) pigmentation
- A. Smoker's melanosis is real and is a genuine differential in this patient, but it is ACQUIRED and typically most marked on the anterior labial gingiva, appearing after the smoking habit begins. Pigmentation present for as long as he can remember is physiological.
- B. CORRECT. Physiological pigmentation is normal melanin deposition by melanocytes in the basal layer of the gingival epithelium. It is symmetrical, most pronounced on the attached gingiva, present from an early age, stable over time, asymptomatic and entirely benign. Its prevalence is highest in individuals with darker skin.
- C. Addisonian pigmentation is generalised and diffuse, affects the buccal mucosa and lips as well as the gingiva, is of RECENT onset, and comes with systemic features — fatigue, weight loss, hypotension, salt craving. This patient's pigmentation is lifelong and he has no systemic complaints.
- D. An amalgam tattoo is a FOCAL blue-grey macule adjacent to a restoration or an extraction site where metal fragments were embedded — not a symmetrical bilateral distribution across both arches.