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Energy dispersive X-ray microanalysis is a powerful tool that can reveal the presence and relative quantities of elements in minute particles in biologic materials. Although this technique has been used in some aspects of dental research, it has rarely been applied to diagnostic oral pathology. The purpose of this paper is to inform practicing dentists and oral specialists about the diagnostic potential of this procedure by presenting three case reports. The first case involved the identification of flakes of a metallic material claimed by a 14-year-old girl to appear periodically between her mandibular molars. In the second case, a periodontist was spared a lawsuit when a freely mobile mass in the antrum of his patient was found to be a calcium-phosphorus compound not related to the periodontal packing that had been used. The third case involved the differential diagnosis of amalgam tattoo and graphite tattoo in a pigmented lesion of the hard palate mucosa. The results of the analyses were significant and indicate a role for this technique in the assessment of selected cases. Potential for wider use of energy dispersive X-ray microanalysis in diagnostic oral pathology exists as research progresses.

A series of 268 cases of amalgam tattoo is analyzed both clinically and histologically. The most common location was the gingiva and alveolar mucosa, followed by the buccal mucosa. Histologically, the amalgam was present in the tissues as discrete, fine, dark granules and as irregular solid fragments. The dark granules were arranged mainly along collagen bundles and around blood vessels. They were also associated with the walls of blood vessels, nerve sheaths, elastic fibers, basement membranes of mucosal epithelium, striated muscle fibers, and acini of minor salivary glands. Dark granules were also present intracellularly within macrophages, multinucleated giant cells, endothelial cells, and fibroblasts. Although in 45% of the cases there was no tissue reaction to the amalgam, in 17% there was a macrophagic reaction and in 38% there was a chronic inflammatory response, usually in the form of a foreign body granuloma, with multinucleated giant cells of the foreign body and Langhans types. Asteroid bodies were also found in some of the foreign body giant cells.

Amalgam tattoos are common oral lesions. The case presented here involved a 33-year-old woman who had had an amalgam tattoo for 2 years and complained of localized soreness and occasional swelling as well as systemic symptoms of weight loss, fatigue, sinusitis, and headaches. After excisional biopsy of the lesion, the patient's complaints ceased dramatically. It is suggested that alterations in healing due to the presence of amalgam particles led to systemic as well as local disease.

A case of foreign-body reaction to amalgam tattoo in edentulous gingiva is described. Asteroid bodies were found inside giant cells of the reactive tissue. The similarities of these bodies to those seen in other diseases are discussed.