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Objectives The aim of this study was to determine the prevalence and clinical features of pigmented oral lesions from Thailand. Materials and Methods Biopsy records of the Department of Oral Pathology, Chulalongkorn University, Department of Oral Diagnosis, KhonKaen University, Department of Oral Biology and Oral Diagnostic Sciences, Chiangmai University, Department of Stomatology, Prince of Songkla University, and Rangsit University were reviewed for oral pigmented lesions diagnosed during 1999 to 2019. Demographic data were culled from the biopsy records. Ages of the patients were subdivided into 10-year intervals. Locations of the lesions were classified as gingiva, labial/buccal mucosa, palate, floor of the mouth, tongue, as well as the combination of sites. Data were analyzed by descriptive statistics using SPSS version 20.0. Results Of the 47,175 accessioned cases, 241 cases (0.51%) were diagnosed in the category of pigmented oral lesions. The age of the patients ranged from 1 month to 88 years with the mean ± standard deviation = 38.74 ± 20.96 years. Regarding gender, 172 patients (71.37%) with pigmented lesions were females, while 69 patients (28.63%) were males. The female-to-male ratio was 2.49:1. The majority of the pigmented lesions were encountered at the gingiva (29.88%) followed by labial/buccal mucosa (26.97%), palate (14.94%), lip (10.79%), alveolar mucosa (9.54%), and others (7.88%), respectively. The three most common pigmented oral lesions in the present study were nevus (39.83%), followed by melanotic macule (28.63%) and amalgam tattoo (17.43%), respectively. Conclusions The most common pigmented oral lesion in the present study is nevus. Demographic data of the patients in the present study are in accordance with previous studies with minor differences. Even though pigmented lesions of the oral cavity constitute a small portion of the oral pathology biopsies, accurate diagnosis is important since there is an overlap in clinical appearance of benign pigmented lesions and melanoma.

Made available in DSpace on 2022-04-29T08:35:47Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-01-01 Oral pigmented lesions can be physiological or pathological, exogenous or endogenous, as well as focal, multifocal, or diffuse. Among them, the oral melanotic macule (OMM) is a small, well-delimited brown-to-black macule, often affecting the lip and gingiva. Amalgam tattoo (AT) is a grey or black area of discoloration on the oral mucosa as a result of entry of dental amalgam into the soft tissues, commonly gingiva and alveolar ridge. Herein, we present a patient with gingival pigmentation with features of both OMM and AT in the same location. Department of Pediatric Dentistry Riberão Preto Dental School (FORP/USP) University of São Paulo, Riberão Preto Department of Diagnosis and Surgery Araraquara Dental School Universidade Estadual Paulista (UNESP) Oral Pathology Department of Stomatology Public Oral Health and Forensic Dentistry Ribeirão Preto Dental School (FORP/USP) University of São Paulo, Riberão Preto Department of Diagnosis and Surgery Araraquara Dental School Universidade Estadual Paulista (UNESP)

Pigmentation is a common clinical finding of an oral cavity, but a proper diagnosis of the lesions is very challenging. Pigmentation can be focal, multifocal, associated with systemic/genetic disorder, or due to exogenous agents. Pigmented lesions are either melanocytic or nonmelanocytic. Pigmented lesions of the oral cavity have a broad spectrum of diversity. They present as racial pigmentation, innocuous lesions (amalgam tattoo, oral melanotic macule), benign nevi, and life-threatening malignant melanoma, and they can also produce a diagnostic dilemma. Thus, a proper diagnosis of a pigmented lesion in an early stage is very important for the accurate treatment plan. In this review, pigmented lesions of the oral cavity are briefly discussed.

BACKGROUND Reflectance confocal microscopy (RCM) is a developing approach for noninvasive detection of oral lesions with label-free contrast and cellular-level resolution. For access into the oral cavity, confocal microscopes are being configured with small-diameter telescopic probes and small objective lenses. However, a small probe and objective lens allows for a rather small field-of-view relative to the large areas of tissue that must be examined for diagnosis. To extend the field-of-view for intraoral RCM imaging, we are investigating a video-mosaicking approach. METHODS A relay telescope and objective lens were adapted to an existing confocal microscope for access into the oral cavity. Imaging was performed using metal three-dimensional-printed objective lens front-end caps with coverslip windows to contact and stabilize the tissue and set depth. Four healthy volunteers (normal oral mucosa), one patient (with an amalgam tattoo) in a clinical setting, and 20 anesthetized patients (with oral squamous cell carcinoma [OSCC]) in a surgical setting were imaged. Instead of the usual still RCM images, videos were recorded and then processed into video-mosaics. Thirty video-mosaics were read and qualitatively assessed by an expert reader of RCM images of the oral mucosa. RESULTS Whereas the objective lens' native field-of-view is 0.75 mm × 0.75 mm, the video-mosaics display larger areas, ranging from 2 mm × 2 mm to 4 mm × 2 mm, with resolution, morphologic detail, and image quality that is preserved relative to that observed in the original videos (individual images). Video-mosaics in healthy volunteers' and the patients' images showed cellular morphologic patterns in the lower epithelium and at the epithelial junction, and connective tissue along with capillary loops and blood flow in the deeper lamina propria. In OSCC, tumor nests could be observed along with normal looking mucosa in margin areas. CONCLUSIONS Video-mosaicking is a reasonably quick and efficient approach for extending the field-of-view of RCM imaging, which can, to some extent, overcome the inherent limitation of an intraoral probe's small field-of-view. Reading video-mosaics can mimic the procedure for examining pathology: initial visualization of the spatial cellular and morphologic patterns of the tumor and the spread of tumor margins over larger areas of the lesion, followed by digitally zooming (magnifying) for closer inspection of suspicious areas. However, faster processing of videos into video-mosaics will be necessary, to allow examination of video-mosaics in real-time at the bedside. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Background Pigmented lesions are uncommon in the oral mucosa, and studies investigating the incidence and types of these lesions are desired to improve the diagnostic knowledge of clinicians. The aim of this study was to analyze the distribution of oral pigmented lesions in a Brazilian population. Material and Methods A retrospective descriptive cross-sectional study was performed. Oral pigmented lesions were retrieved from the files of two oral and maxillofacial pathology services from Brazil over a 45-year period (1974-2019). The clinical data and the diagnoses of each case were retrieved and included in a Microsoft Excel® database. Results From 77.074 lesions diagnosed in this period, 761 (0.99%) represented pigmented lesions of the oral mucosa, including 351 (46.1%) melanocytic and 410 (53.9%) non-melanocytic lesions, with a higher incidence in females (73.2%) between the fourth and seventh decades of life. Amalgam tattoo (53.6%) represented the most common lesion, followed by melanotic macule (18.3%) and racial pigmentation (10.8%). Other pigmented lesions included nevus (9.9%), post-inflammatory pigmentation (3%), melanoma (2.1%), melanoacanthoma (1.4%), smoker's melanosis (0.4%), drug-induced pigmentation (0.3%), and melanotic neuroectodermal tumor of infancy (0.1%). The buccal mucosa was the most commonly affected site (25.2%), followed by the alveolar ridge (14.5%), and gingiva (11.8%). Conclusions The current findings were similar to previous studies with minor differences due methodology and characteristics of the services from where lesions were retrieved. The knowledge of these data may contribute to a better understanding of oral pigmented lesions and assist clinicians to better recognize and manage them. Key words:Pigmented lesions, pigmentation, melanin, amalgam, oral cavity.

Black and brown pigmentation of the oral mucosa can occur due to a multitude of non-neoplastic causes. Endogenous or exogenous pigments may be responsible for oral discoloration which can range from innocuous to life-threatening in nature. Physiologic, reactive, and idiopathic melanin production seen in smoker’s melanosis, drug-related discolorations, melanotic macule, melanoacanthoma and systemic diseases are presented. Exogenous sources of pigmentation such as amalgam tattoo and black hairy tongue are also discussed. Determining the significance of mucosal pigmented lesions may represent a diagnostic challenge for clinicians. Biopsy is indicated whenever the source of pigmentation cannot be definitively identified based on the clinical presentation.

Periodontal health is defined by absence of clinically detectable inflammation. There is a biological level of immune surveillance that is consistent with clinical gingival health and homeostasis. Clinical gingival health may be found in a periodontium that is intact, i.e. without clinical attachment loss or bone loss, and on a reduced periodontium in either a non-periodontitis patient (e.g. in patients with some form of gingival recession or following crown lengthening surgery) or in a patient with a history of periodontitis who is currently periodontally stable. Clinical gingival health can be restored following treatment of gingivitis and periodontitis. However, the treated and stable periodontitis patient with current gingival health remains at increased risk of recurrent periodontitis, and accordingly, must be closely monitored. Two broad categories of gingival diseases include non-dental plaque biofilm-induced gingival diseases and dental plaque-induced gingivitis. Non-dental plaque biofilm-induced gingival diseases include a variety of conditions that are not caused by plaque and usually do not resolve following plaque removal. Such lesions may be manifestations of a systemic condition or may be localized to the oral cavity. Dental plaque-induced gingivitis has a variety of clinical signs and symptoms, and both local predisposing factors and systemic modifying factors can affect its extent, severity, and progression. Dental plaque-induced gingivitis may arise on an intact periodontium or on a reduced periodontium in either a non-periodontitis patient or in a currently stable "periodontitis patient" i.e. successfully treated, in whom clinical inflammation has been eliminated (or substantially reduced). A periodontitis patient with gingival inflammation remains a periodontitis patient (Figure 1), and comprehensive risk assessment and management are imperative to ensure early prevention and/or treatment of recurrent/progressive periodontitis. Precision dental medicine defines a patient-centered approach to care, and therefore, creates differences in the way in which a "case" of gingival health or gingivitis is defined for clinical practice as opposed to epidemiologically in population prevalence surveys. Thus, case definitions of gingival health and gingivitis are presented for both purposes. While gingival health and gingivitis have many clinical features, case definitions are primarily predicated on presence or absence of bleeding on probing. Here we classify gingival health and gingival diseases/conditions, along with a summary table of diagnostic features for defining health and gingivitis in various clinical situations. ispartof: JOURNAL OF PERIODONTOLOGY vol:89 pages:S74-S84 ispartof: location:IL, Chicago status: published

none 10 no Oral pigmentations (OPs) are often neglected, although a meticulous examination of the oral cavity is important not only in the diagnosis of oral melanoma, but also for the detection of important clinical findings that may indicate the presence of a systemic disease. OPs may be classified into two major groups on the basis of their clinical appearance: focal and diffuse pigmentations, even though this distinction may not appear so limpid in some cases. The former include amalgam tattoo, melanocytic nevi, melanoacanthoma and melanosis, while the latter include physiological/racial pigmentations, smoker's melanosis, drug-induced hyperpigmentations, postinflammatory hyperpigmentations and OPs associated with systemic diseases. We will discuss the most frequent OPs and the differential diagnosis with oral mucosal melanoma (OMM), underlining the most frequent lesions that need to undergo a bioptic examination and lesions that could be proposed for a sequential follow-up. none Lambertini, M; Patrizi, A; Fanti, P A; Melotti, B; Caliceti, U; Magnoni, C; Misciali, C; Baraldi, C; Ravaioli, G M; Dika, E Lambertini, M; Patrizi, A; Fanti, P A; Melotti, B; Caliceti, U; Magnoni, C; Misciali, C; Baraldi, C; Ravaioli, G M; Dika, E

O objetivo da pesquisa é realizar um estudo retrospectivo de lesões pigmentadas na mucosa bucal e discutir aspectos importantes de seu diagnóstico e tratamento diferenciado na prática odontológica. Métodos: Trata-se de um estudo retrospectivo descritivo de lesões pigmentadas na cavidade oral que foram registradas e diagnosticadas na clínica de Estomatologia e laboratório de Patologia Oral por um período de 28 anos. Resultados: Ocorreram 172 casos de lesões pigmentadas em um total de 13.743 registros, correspondendo a uma prevalência de 1,25% neste serviço. O sexo feminino foi responsável por 61,6% dos casos. A faixa etária mais afetada foi de 31 a 40 anos (23,8%). A localização anatômica mais comum envolvida foi a mucosa da bochecha (20,19%), seguida pelo lábio inferior (19,2%) e crista alveolar (15,2%). Tatuagem de amálgama e mácula melanótica (33,1%) foram as lesões pigmentadas mais comuns, seguidas por nevo melanocítico (21,6%). A falta de algumas informações nos formulários de solicitação de biópsia foi a principal limitação do estudo. Conclusão: Lesões orais pigmentadas eram incomuns no serviço analisado, provavelmente porque nem todas foram encaminhadas para análise histopatológica. No entanto, um diagnóstico correto é importante para que os pacientes recebam tratamento adequado.

Melanoacanthoma is a blackened mucocutaneous lesion, mainly affecting individuals with dark skin and exhibiting rapid development. Differential diagnosis includes nevus, amalgam tattoo and melanoma. This article reports a case of a 53-year-old white woman, who exhibited multiple blackened lesions on the gingiva and upper lip. After incisional biopsy, the presence of numerous melanin-containing dendritic cells distributed throughout the epithelial thickness, which were S-100 (+), were observed microscopically. Final diagnosis was multifocal oral melanoacanthoma. Follow-up for 28 months has shown appearing of more lesions in gingiva and upper lip. Therefore, the importance of differential diagnosis of oral melanoma with the group of oral pigmented lesions, and possible associated systemic diseases were evaluated. Key words:Melanocytes, pigmentation, oral mucosa, gingiva, differential diagnosis.

Introduction: An amalgam tattoo is the most common form of exogenous oral pigmentation caused by the diffusion of dental amalgam into the soft tissue. Observation: Here we describe a case of diffuse pigmentation of amalgam on the hard palate. Discussion: Mucosal hyperpigmentation can occasionally be confused with melanotic lesions, thereby requiring a biopsy for differential diagnosis. Once the diagnosis of an amalgam tattoo has been established, the removal of the lesion is not necessary, except for aesthetic reasons.

The majority of oral pigmentations are benign lesions such as nevi, melanotic macules, melanoacanthomas or amalgam tattoos. Conversely, mucosal melanomas are rare but often lethal; therefore, excluding oral melanomas in this setting is crucial. Reflectance confocal microscopy is a non-invasive, in vivo imaging system with cellular resolution that has been used to distinguish benign from malignant pigmented lesions in the skin, and more recently in the mucosa. However, lesions located posteriorly in the oral cavity are difficult to assess visually and difficult to biopsy due to their location. Herein we present a patient with previous multiple melanomas presenting with an oral amalgam tattoo in the buccal mucosa, which was imaged using an intraoral telescopic probe attached to a commercially available handheld RCM. In this case report we describe this novel probe, the first RCM description of an amalgam tattoo and we discuss its differences with the findings described in oral melanomas.

Little attention has been paid to the toxicity of silver amalgam fillings, which have been used over the centuries in Dentistry. Amalgam particles may accidentally and/or traumatically be embedded into the submucosal tissue during placement of a restoration and perpetuate in such area. This article presents a case of amalgam tattoo and investigates whether it is related to the patient's repeated episodes of sinusitis. The patient was a 46-year-old woman with a 2 mm diameter radiopaque lesion in the right oral mucosa detected on a panoramic radiograph and presented as a black macula clinically. A complete surgical resection was carried out. The histopathological examination revealed deposits of dark-brownish pigments lining the submucosal tissue with adjacent lymphocytic inflammatory infiltrate and multinucleated giant cells phagocyting pigments. There was a negative staining for both iron and melanin. One year after lesion removal, the patient reported that the sinusitis crises had ceased after repeated episodes for years. It may be speculated that the inflammatory process related to amalgam tattoo seems to lead to a local immune response that causes sinusitis because it enhances the human leukocyte antigen DR (HLA-DR) tissue expression.

researched mercury poisoning and identified through his research that silver amalgam fillings in the mouth were a source of mercury vapor. More recently, many studies reported that amalgam may constitute potential toxic hazards to patients through mercury release and absorption, surface corrosion, and the reaction of released mercury with residual alloy particles to form additional inter metallic compounds. Furthermore, mercury may migrate gradually from an amalgam restoration into the enamel, dentin, pulp tissues, and adjacent gingival tissue where it accumulates [1]. Increased mercury levels in the gingiva adjacent to sub gingival amalgam restorations have been reported. In addition, fine amalgam particles may become accidentally embedded in the soft tissues of the mouth, most commonly the gingiva, when they are abraded by high speed rotary instruments, during the removal of the amalgam fillings and preparation of crowns over amalgam cores. Moreover, this can occur when amalgam is used as a retrograde root filling material, and produces tattoo [2]. Examinations of tissue biopsies from both human and experimental animal lesions by light, electron microscopy and energy dispersive x-ray micro-analysis have shown that the small particles of amalgam undergo progressive degradation within phagocytic cells, with a subsequent redistribution of their constituted elements. Fine secondary particles containing silver become widely distributed in tissues, producing the characteristic tattooing, thereafter, mercury is released into surrounding soft tissues [3]. Amalgam debris is able to activate immunologic adaptive reaction where tissue reaction to amalgam tattoo depends on amalgam particles size and composition. While copper and zinc are rapidly lost from the area of the tattoo, mercury and tin are lost more slowly and finally silver remains permanent in the tissues. The residual elements of amalgam tattoo develop a noxious effect within soft tissues, where mercury passes from the tissue fluid into the blood stream and accumulates in the kidneys [4]. Exposure to large amounts of metallic mercury vapor, compared to small amounts released from amalgam fillings, causes certain symptoms that may include cough, fever, skin rashes, tremors, difficulty in muscle coordination and walking, renal abnormalities, and memory loss [5]. Patients allergic to mercury used in dental clinics may experience itching, hives, local soreness, burning, and dryness of throat and mouth. Several studies reported a strong relationship between the total surface areas of amalgam restorations and blood or urine mercury levels [6]. Heintze et al. [7] reported in vitro formation of methyl mercury from a conventional and mixed amalgam by the action of streptococcus sanguis, mutans and mitior in pure cultures, suggesting the possibility of methyl mercury formation in the mouth if amalgam is present. Mercury compounds have high affinity to proteins, amino acids, purine, pyrimidine and nucleic acid [8]. Mercury toxicity was explained by its interaction with these molecules through sulfhydryl groups, and disulfide bonds on cell membrane; thus, mercury compounds alter the selective permeability of cell membranes for ions and nutrients and possibly block more specific membrane transport processes. Fetal exposure may follow previous mercury uptake by a pregnant mother where mercury compounds, as most other substances, may pass through the placenta to the fetal circulation [9]. Fetal toxicity occurs following certain degrees of mercury compounds accumulation within the central nervous system. Although studies shown that little mercury compounds penetrate to fetal tissues, embryopathic effects of these compounds have been demonstrated as growth retardation, subcutaneous edema, exencephaly, anophthalmia, and teratogenic effects, such as cleft lip and palate, ribs fusion and syndactylia and embryopathic death. Therefore, the safety of dental amalgam-released-mercury during pregnancy became questionable. Data from Soussa E [10] study shows a positive correlation between blood mercury levels in mothers and their oral tissue response; however, the negative impact of mercury on oral tissues is regarded to have taken place during pregnancy in relation to elevated blood mercury levels of mothers. Monitoring the blood mercury following dental amalgam restorations during pregnancy is recommended to avoid its harmful effect on the fetus. The World Health Organization (WHO) has stated that there is no safe level of mercury. That means that no amount of mercury is safe, not even one atom. Even if enough mercury hasn’t accumulated to manifest a symptom directly or indirectly related to chronic mercury poisoning, The World Health Organization, O.S.H.A., N.I.O.S.H., etc, all agree that mercury is an environmental poison and have established specific occupational exposure limits. The Environment Protection Agency has declared amalgam removed from teeth to be a toxic waste. Even the American Dental Association warns that amalgam filling material is hazardous to dental office personnel, Editorial

The aim of this study was to investigate the long-term effects of alloys containing silver (mainly Ag-Sn alloy) on oral mucous tissue. We observed biopsy tissue specimens from patients diagnosed as having amalgam tattoo and/or metal pigmentation by light and electron microscopy and electron-probe microanalysis (EPMA). In most cases, Ag-Sn alloy was present in the tissue but it could not be confirmed if the alloy originated from amalgam. Distributions of both Ag-S and Ag-Sn have typical patterns. Most Ag forms Ag2S and is stably deposited in three patterns along the collagen, basement membrane, and fibrous cells without inducing any host reaction. On the other hand, Sn forms large granules that contain Ag, S, C, N, P, and Ca, and is in soft state in the tissue. Tissue reactions to the alloy become weaker as time passes.

Mucosal melanoma of the oral cavity is a rare but highly aggressive neoplasm. However, the clinicians need to be aware of the other and more frequent etiologies of intraoral pigmentation, such as amalgam tattoos. As amalgam has been extensively used for dental restorations and can cause pigmentations in the oral mucosa, this is a differential diagnosis not to be forgotten. We describe the characteristics of these two phenomena and present a case vignette illustrating the differential diagnostic issues. Other causes of intraoral pigmentation are summarized.

s / Toxicology Letters 238S (2015) S56–S383 S159 P05-059 Levels of mercury in amalgam tattoos G. Guzzi1,∗, F. Spadari2, G.P. Bombeccari2, I. Bolengo1,∗, L. Brambilla3, S. Ferrucci3, A. Ronchi4, P.D. Pigatto5, F. Pallotti 6 1 Italian Association for Metals and Biocompatibility Research – A.I.R.M.E.B., Dental Toxicology, Milan, Italy 2 Ospedale Maggiore Policlinico Fondazione Ca’ Granda IRCCS, University of Milan, Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Pathology and Medicine, Milan, Italy 3 Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Operative Unit of Dermatology, Milan, Italy 4 IRCCS Maugeri Foundation and University of Pavia, Italy, Pavia Poison Control Center and National Toxicology Information Centre, Toxicology Unit, Pavia, Italy 5 IRCCS Galeazzi Hospital, University of Milan, Milan, Italy, Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Pathology and Medicine, Milan, Italy 6 Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Unit of Anatomical Pathology, Milan, Italy Question: Mercury is thought to be deposit in amalgam tattoo, which are oral localized black-bluish pigmentation, but there are no reports documenting the presence of inorganic and/or organic mercury in amalgam tattoos in the oral cavity in humans. Methods: The content of total mercury in amalgam tattoo due to mercury released from mercury-containing amalgam fillings was determined in 5 specimens of amalgam tattoo. We analyzed at about 50–200mgwet weight of tissue for each specimen and fixed in 10 percent formaldehyde, and compared with the levels of total mercury of 20 gingiva specimens without amalgam tattoo. Results: Total mercury levels were elevated in all specimens of amalgam tattoo we analyzed (5 of 5), as it greatly exceeds the normal range 2 g/g (toxic level, >200). The mean mercury level in amalgam tattoo was 82.12 g/g as compared with 0.204 micrograms per gram in controls. We found that the content of the total mercury in amalgam tattoo specimens ranged from3.2 to 358 g/g. In one amalgam tattoo tissue with the highest mercury level was also observed a high level of silver (Ag) 94.5 g/g (threshold limit value). Conclusions: Amalgam tattoo had elevated total mercury levels. http://dx.doi.org/10.1016/j.toxlet.2015.08.492 P05-060 Quantification of buprenorphine and the metabolites of methadone and heroin in hair of patients in rehabilitation programs by GC–MS D. Lima1,2,∗, F. Marques2, A. Duarte2, C.M. Afonso3, F. Carvalho1, R. Dinis-Oliveira1,∗ 1 University of Porto, Laboratory of Toxicology, Porto, Portugal 2 Fluminense Federal University, Department of Analytical Chemistry, Niteroi, Brazil 3 University of Porto, Center of Medical Chemistry, Porto, Portugal Hair analysisprovides informationaboutuseofdrugsovera long period. In thepresent studyamethodology aimed the simultaneous quantification of buprenorphine, ofmethadone and itsmetabolites, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) and 2ethyl-5-methyl-3,3-diphenyl-1-pyrrolidine (EMDP), and of heroin metabolites, morphine and 6-acetylmorphine (6-AM), in hair samples collected from drug abusers enrolled in methadone treatment program for heroine addition. Ethylmorphine was used as internal standard. Washing, spiking and extraction studies of hair drugs were developed. After decontaminationwith n-hexane, an amount of 30mg of powdered real hair samples were placed in a tube and 1mL of hydrochloric acid 0.1mol/L. After overnight incubation at 60 ◦C the solution was neutralized with 1mL of NaOH 0.1mol/L and buffered with 1mL of phosphate buffer pH 7.0. Samples were centrifuged at 4000 rpm for 5min, the supernatant being collected and purified by solid-phase extraction using mixed-mode extraction cartridges (MCX). The analytes were eluted with 2mL of a mixture of methanol:ammonia (5%). The obtained solutions were evaporated to dryness under a streamof nitrogen and subsequently resuspended with 50 L derivatizing N-methyl-N-(trimethylsilyl) trifluoroacetamide (MSTFA). Blank, standards and samples were analyzed by gas chromatography/electron impact-mass spectrometry (GC-EI/MS). Selectivity, linearity, analytical limits (i.e., limit of detection and low limit of quantification – LOD and LLOQ), carryover, precision, accuracy and recovery were evaluated. A number of 10 hair samples from human subjects following a long-term methadone therapy were analyzed by this method. All analytes were identified except EMDP, possibly because its represents less than 10% of methadone metabolites and hair excretion may not be substantial.Methadone andmorphinewere found in all samples, 6AM in four samples and EDDP in three samples of the samples analyzed. In conclusion, the developedmethod can be applied in forensic and clinical routine during therapeutic rehabilitation programs. http://dx.doi.org/10.1016/j.toxlet.2015.08.493 P05-061 Gynecomastia associated with mercury-containing dental amalgam fillings I. Bolengo1,∗, A. Ronchi2, P.D. Pigatto3, G.P. Bombeccari4, F. Spadari4, G. Guzzi1 1 Italian Association for Metals and Biocompatibility Research – A.I.R.M.E.B., Dental Toxicology, Milan, Italy 2 IRCCS Maugeri Foundation and University of Pavia, Pavia Poison Control Center and National Toxicology Information Centre, Toxicology Unit, Pavia, Italy 3 IRCCS Galeazzi Hospital, University of Milan, Milan, Italy, Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Pathology and Medicine, Milan, Italy 4 Ospedale Maggiore Policlinico Fondazione Ca’ Granda IRCCS, University of Milan, Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Pathology and Medicine, Milan, Italy Question:Wepresent a casewheregynecomastiawas associated with overexposure to mercury-containing amalgam. July 2002, a 31-year-old man was referred to us because of permanent sensation of metallic taste. He has simply not taste for water and he had chronic fatigue. December 2001, he had a painful enlargement of the left breast that was diagnosed as idiopathic gynecomastia. He showed 7 mercury fillings and one gold crown on his upper right first molar. Methods: Patient received an extensive laboratory investigation. Results: Levels of mercury in chewing gum-stimulated whole saliva was 211.6 g/l [limit values: were elevated in association with thedyspepsia, andwas a clear-cut evidenceof toxic local effect on papillae gustative due to mercury exposure. Conclusions: Our case report documented a temporal relation between mercury amalgam-replacement and the resolution of signs and symptoms of gynecomastia. http://dx.doi.org/10.1016/j.toxlet.2015.08.494

Tatuagens por amálgama são lesões pigmentadas, exógenas, de frequente ocorrência na mucosa bucal, que resultam da introdução acidental de partículas de amálgama nos tecidos moles. O diagnóstico da tatuagem por amálgama é simples, geralmente, baseado em achados clínicos, complementado pela história recente ou pregressa de remoção de restauração por amálgama. Radiografias intraorais podem ser úteis na detecção de radiopacidade, associadas à partícula de amálgama. Nos casos em que as tatuagens por amálgama não permitem diferenciação de outras lesões melanocíticas, o exame histopatológico deve ser realizado. Os autores relatam à ocorrência de lesão extensa por tatuagem de amálgama com confirmação histopatológica.

The most common oral solitary pigmented lesion is the dental amalgam tattoo. It occurs as a result of colouring of the tissue by alien pigment which was administered intra or subepidermaly either intentionally or accidentally. The most common material used for the colouring of the oral mucosa is amalgam from amalgam fillings and metal particles from prosthetic restorations which are absorbed accidentally. The oral mucosa tattoos are most often found in the area of the marginal gingiva or the buccal mucosa. The metal particles may accidentally reach the area of the oral mucosa during various dentistry interventions. The therapy most often involves surgical intervention with excisional biopsy while in the recent period the low power laser therapy has provided exceptional results. The aim of the paper was to present the successful removal of the oral mucosa tattoo in a single visit.

Los tatuajes por amalgama se presentan debido a la ocurrencia accidental de compuestos de plata en el tejido conjuntivo mucoso con frecuencia producen una pigmentación negragrisácea que genera un tatuaje permanente que con frecuencia, estas alteraciones estéticas son de origen iatrogénico, lo que motiva al paciente a acudir a la consulta odontológica. Su prevalencia es del 8%, por lo cual es necesario que el odontólogo tenga conocimiento del diagnóstico y tratamiento a realizar. El objetivo fue describir desde una perspectiva interdisciplinaria, el tratamiento de un caso clínico en el que se presenta un tatuaje periodontal por amalgama, generado por una obturación retrograda iatrogénica realizada con dicho material. En el presente artículo se reporta un caso de paciente femenino de 52 años de edad, cuyo motivo de consulta fue “quiero que me blanqueen este diente”. Se obtuvo como diagnóstico integral: perforación lateral de raíz con fístula activa, pigmentación dentaria, restauración y tratamiento endodóntico defectuosos en el 11, y tatuaje periodontal. El tratamiento fue enfocado desde el punto de vista endodóntico, periodontal y protésico, iniciando la obturación retrógrada con MTA® para sellar la falsa vía, injerto gingival libre, y realización de corona total metal-cerámica con collar cerámico, obteniéndose resultados satisfactorios desde el punto de vista funcional y estético con un pronóstico bueno. Se pudo concluir que los procedimientos interdisciplinarios aplicados en este caso son una alternativa adecuada para el tratamiento del tatuaje periodontal por amalgama. Amalgam periodontal tatoos take place as a result of the accidental occurrence of silver compounds on the connective tissue that frequently produce a grayish-black pigmentation that generates a permanent tattoo. Those aesthetic changes are iatrogenic in nature, which motivates the patient to go to the dentist. Their prevalence reaches 8% for which it is necessary for the dentist to know the appropriate diagnosis and treatments. The objective was to describe, from an interdisciplinary perspective, the treatment used in a clinical case in which the patient presented a periodontal tattoo for amalgam generated by an iatrogenic retrograde obturation. In the present article it is reported a case of a 52 years old female patient whose reason for going to the dentist was “I want this tooth to be bleached”. An integral diagnosis was provided: lateral perforation of root active fistula, dental pigmentation, defective restoration and endodontic treatment in 11, and periodontal tattoo. Treatment was approached from the endodontic, periodontal, and prosthetic point of view; it started with an MTA® retrograde obturation to seal the false route, free gingival raft, and total metal-ceramic crown. Satisfactory results were obtained from the functional and aesthetic perspective with a favorable prognosis. It was concluded that interdisciplinary procedures applied in this case are a suitable alternative for treatment of periodontal amalgam tattoo. 34-42 nancykarina.mp@gmail.com

espanolEl tatuaje por amalgama tambien conocido como pigmentacion por amalgama, es el producto del deposito en el tejido conectivo subepitelial de residuos de amalgama resultado de procedimientos iatrogenicos por parte del odontologo. La presentacion clinica varia dependiendo de la profundidad a la que se alberguen las particulas en el tejido, radiograficamente se puede identificar la radiopacidad correspondiente al fragmento de amalgama, en los estudios histopatologicos se pueden observar las particulas de amalgama como granulos oscuros, solidos e irregulares dispuesto entre los haces de colageno y vasos sanguineo. El presente articulo refiere un peculiar caso de tatuaje por amalgama de tonalidades azules y negras que se extendio difusa e irregularmente en toda la mucosa vestibular desde el organo dentario 21 hasta region premolar izquierda. Al realizar una cirugia periodontal exploratoria se detecto una gran porcion de amalgama utilizada como material obturador y restaurador radicular del 21. Durante el procedimiento quirurgico se cureteo y adelgazo la cara interna del colgajo mucoperiostico para tratar de disminuir el grado de pigmentacion. EnglishAmalgam pigmentation or amalgam tattoo is the product of the deposit in the subepithelial connective tissue of amalgam was the iatrogenic result of procedures by the dentist. The clinical presentation varies depending on the depth at which the particles are housed in the tissue can be identified radiographically radiopacity fragment corresponding to the amalgam, histopathological studies particles can be observed as dark granules amalgam, provided solid, irregular between collagen bundles and blood vessels. The present article describes an unusual case of focal argyrosis shades of blue and black fuzzy and unevenly spread across the buccal mucosa from 21 to left premolar region. When performing exploratory periodontal surgery revealed a large portion of amalgam used as a restorative filling material and root of 21. During the surgical procedure and lost cureteo the inside of the mucoperiosteal flap to try to reduce the degree of pigmentation.

Purpose: Black macules on the oral mucosa may be diagnostic of melanotic macule, melanotic nevus, amalgam tattoo or oral pigmented lesions caused by endodontic sealers, vascular lesions and melanoma. The differential diagnosis of such lesions is important as melanoma may be quite serious and must be treated quickly. A case of black macule on the oral mucosa is reported here, focusing on the importance of the differential diagnosis instituted. Case description: A 56-year-old female patient with a previous history of cutaneous melanoma consulted the Stomatology Service for evaluation of a black macule on the floor of the mouth. The diagnosis was found to be amalgam tattoo, although a radiographic exam had not shown an image compatible with amalgam. Conclusion: The diagnosis of amalgam tattoo can be confirmed by the detection of a metallic fragment in a radiographic exam, a situation that dispenses with the institution of treatment. However, if such a fragment is not detected, a biopsy is necessary to rule out the diagnostic hypothesis of melanocytic neoplasia. Objetivo: As máculas negras que acometem a mucosa oral incluem os diagnósticos de mácula melânica, nevo melânico, tatuagem por amálgama ou por cimento endodôntico, lesões vasculares e melanoma. O diagnóstico diferencial de tais lesões é importante considerando-se a gravidade desta última. Os autores relatam um caso de mácula negra na mucosa oral enfatizando a importância do diagnóstico diferencial e a conduta instituída. Descrição do caso: Paciente do sexo feminino, 56 anos de idade, com história prévia de melanoma cutâneo, consultou o Serviço de Estomatologia para avaliação de mácula negra em assoalho de boca. O diagnóstico foi de tatuagem por amálgama, embora o exame radiográfico não exibisse imagem compatível com fragmento metálico. Conclusão: O diagnóstico de tatuagem por amálgama pode ser confirmado por meio da detecção de fragmentos metálicos ao exame radiográfico, situação que dispensa a instituição de tratamento. Entretanto, se os fragmentos não forem detectados, a biópsia se faz necessária para descartar a hipótese de neoplasia melanocítica.

Amalgam has been used for the restoration of teeth for well over 100 years, and is the most successful of the direct restorative materials with respect to longevity. Despite the increasing use of tooth-coloured materials, with advantages of aesthetics and adhesion, amalgam is one of the most widely used dental restorative materials. One of the principal disadvantages of amalgam, apart from aesthetics, is that it may have adverse biological effects, both locally and systemically. Locally, it can cause an erythematous lesion on the adjacent oral soft tissues (tongue and buccal mucosa), and systemically free mercury in the amalgam may give rise to a hypersensitivity reaction. The purpose of this paper is to review the literature concerning the local adverse reactions to dental amalgam. The focus will be on the reactions of the oral mucosa, and brief consideration will be given to laboratory cytotoxicity of dental amalgam and its components, and to the 'amalgam tattoo'.

Despite studies concerning toxic reactions related to amalgam components in the literature, few studies have been devoted to evaluate local noxious effects of amalgam tattoos (AT) on biological tissues. In addition, little is known about activation of inflammatory cells by mucosa-implanted amalgam debris. Tissue reaction to AT depends on the particle size. Human leukocyte antigen DR (HLA-DR) is an activation marker of inflammatory cells associated with antigen presentation. Metallothioneins (MT) are proteins involved with metal detoxication, including mercury and silver. The purpose of the present study was to investigate the immunolocalization of HLA-DR and MT in AT with large or powdered particles. Paraffin-embedded AT tissue blocks were sectioned and subjected to immunohistochemistry for HLA-DR and MT localization. The results demonstrated a dense mononuclear inflammatory infiltrate associated with large and powdered debris and positivity for HLA-DR and MT in inflammatory cells. While blood vessel walls and connective fibers impregnated with powdered particles were negative for HLA-DR, they were positive for MT. In addition, wherever epithelial basement membrane impregnation by powdered amalgam particles was observed, a strong positivity for MT was detected. These findings demonstrate that residual elements of AT still have noxious local effects over tissues. ___________________________________________________________________________________________________ RESUMO Poucos estudos têm investigado a toxicidade tecidual local das tatuagens por amálgama (TA), embora diversos trabalhos demonstrem efeitos nocivos desse material restaurador. Pouco se sabe sobre a ativação de células inflamatórias nesse tipo de lesão. A reação tecidual contra os restos de amálgama varia com o tamanho das partículas implantadas. O antígeno leucocitário humano DR (HLA-DR) está associado com a ativação de células inflamatórias, sendo relacionado à apresentação de antígeno. Metalotioneínas (MT) são proteínas envolvidas com neutralização de metais pesados, tais como mercúrio e prata. O objetivo do presente trabalho foi investigar a imunolocalização de HLA-DR e MT em TA compostas por depósitos teciduais de diferentes tamanhos. Cortes histológicos de lesões fixadas em formol e embebidas em parafina foram submetidos a técnica imunoistoquímica para a detecção dos antígenos mencionados. Os resultados demonstraram denso infiltrado inflamatório associado com partículas grandes ou pulverizadas, observando-se presença de células HLA-DR e MT positivas. Paredes de vasos sangüíneos e fibras de tecido conjuntivo impregnadas por restos de amálgama foram negativas para HLA-DR, mas positivas para MT. Impregnação da membrana basal por partículas de amálgama correspondia a forte positividade para MT no epitélio. Esses resultados demonstram a existência de efeitos nocivos locais das TA sobre os tecidos.

Powdered dental amalgam that had passed through either a 106 microns or a 45 microns sieve was implanted subcutaneously in guinea pigs for periods of up to 2 yr. The renal cortical mercury levels associated with the 106 microns material were on average 16% of those produced by the 45 microns material. A reduction in the amount of 45 microns powder implanted, by a factor of 75%, resulted in a fall of only 27% in renal mercury concentrations. The marked effect of particle size on mercury release may be explained by the large increase in the proportion of implanted material that was degraded within phagocytic cells in the local lesions.

Soft tissue degradation of the 3 principal amalgam phases have been investigated in relation to their role in the formation of the amalgam tattoo. Each phase, finely powdered, was implanted subcutaneously into the submandibular region of guinea-pigs for periods ranging from 1 week to 1 year. The rates of breakdown were assessed radiographically and the final lesions were examined by light and electron microscopy and X-ray microanalysis. γ 2 (Sn 7 Hg) phase degraded rapidly, mainly extracellularly, and did not produce a tattoo. Both mercury and tin disappeared from the lesion, γ 1 (Ag 2 Hg 3 ) phase degraded less rapidly, both extra and intracellularly, and produced a small tattoo. Mercury was lost from the lesion. γ (Ag 3 Sn) phase degraded slowly, intracellularly, and produced a large tattoo. Tattoos always resulted from persistence of minute particles of silver and sulphur associated with basal lamina and connective tissue.

Twenty-four guinea pigs were subcutaneously implanted with 2 X 25 mg of powdered dental amalgam for between 1 and 24 months. Four animals served as controls. All animals were fed a standard diet containing 0.2 microgram/g selenium (Se). Mercury (Hg) was released from the implants at an average rate of 21.7 micrograms/d and 4.35-16.94 micrograms of Se were consumed daily in the diet. The renal Hg rose to a maximum of 263 micrograms/g at 11 months in implanted animals and 6.65 mg Hg was excreted over 2 yr. The renal proximal tubular cells of implanted animals contained visible Hg deposits in secondary lysosomes and within nuclei containing both Hg and Se. No other signs of obvious renal pathology were seen in implanted animals as compared with controls. It would seem likely that the low Se levels present within this standard laboratory diet were sufficient to protect against Hg toxicity.