Black and Brown: Non-neoplastic Pigmentation of the Oral Mucosa

  • Molly S. RosebushEmail author
  • Ashleigh N. Briody
  • Kitrina G. Cordell
Special Issue: Colors and Textures, a Review of Oral Mucosal Entities


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.


Black Brown Pigmentation Oral mucosa Melanin Melanotic Biopsy 




Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Meleti M, Vescovi P, Mooi WJ, van der Waal I. Pigmented lesions of the oral mucosa and perioral tissues: a flow-chart for the diagnosis and some recommendations for the management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(5):606–16.CrossRefGoogle Scholar
  2. 2.
    Muller S. Melanin-associated pigmented lesions of the oral mucosa: presentation, differential diagnosis, and treatment. Dermatol Ther. 2010;23(3):220–9.CrossRefGoogle Scholar
  3. 3.
    Amir E, Gorsky M, Buchner A, Sarnat H, Gat H. Physiologic pigmentation of the oral mucosa in Israeli children. Oral Surg Oral Med Oral Pathol. 1991;71(3):396–8.CrossRefGoogle Scholar
  4. 4.
    Gorsky M, Buchner A, Moskona D, Aviv I. Physiologic pigmentation of the oral mucosa in Israeli Jews of different ethnic origin. Community Dent Oral Epidemiol. 1984;12(3):188–90.CrossRefGoogle Scholar
  5. 5.
    Eisen D. Disorders of pigmentation in the oral cavity. Clin Dermatol. 2000;18(5):579–87.CrossRefGoogle Scholar
  6. 6.
    Mallikarjuna K, Gupta S, Shukla S, Chaurasia S. Unusual extensive physiologic melanin pigmentation of the oral cavity: a clinical presentation. J Indian Soc Pedod Prev Dent. 2013;31(2):121–5.CrossRefGoogle Scholar
  7. 7.
    Alawi F. Pigmented lesions of the oral cavity: an update. Dent Clin N Am. 2013;57(4):699–710.CrossRefGoogle Scholar
  8. 8.
    Sreeja C, Ramakrishnan K, Vijayalakshmi D, Devi M, Aesha I, Vijayabanu B. Oral pigmentation: a review. J Pharm Bioallied Sci. 2015;7(Suppl 2):403–8.CrossRefGoogle Scholar
  9. 9.
    Gaeta GM, Satriano RA, Baroni A. Oral pigmented lesions. Clin Dermatol. 2002;20(3):286–8.CrossRefGoogle Scholar
  10. 10.
    Mignogna MD, Lo Muzio L, Ruoppo E, Errico M, Amato M, Satriano RA. Oral manifestations of idiopathic lenticular mucocutaneous pigmentation (Laugier–Hunziker syndrome): a clinical, histopathological and ultrastructural review of 12 cases. Oral Dis. 1999;5(1):80–6.CrossRefGoogle Scholar
  11. 11.
    Mozaffari HR, Rezaei F, Sharifi R, Mirbahari SG. Seven-year follow-up of Peutz–Jeghers syndrome. Case Rep Dent. 2016;2016:6052181.Google Scholar
  12. 12.
    Nieman LK, Chanco Turner ML. Addison’s disease. Clin Dermatol. 2006;24(4):276–80.CrossRefGoogle Scholar
  13. 13.
    Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S. Addison’s disease. Contemp Clin Dent. 2012;3(4):484–6.CrossRefGoogle Scholar
  14. 14.
    Neville B, Damm D, Allen C, Chi A. Oral and maxillofacial pathology. 4th ed. St. Louis: Elsevier; 2016.Google Scholar
  15. 15.
    Zhang Y, Ke Y, Zheng X, Liu Q, Duan X. Correlation between genotype and phenotype in three families with Peutz–Jeghers syndrome. Exp Ther Med. 2017;13(2):507–14.CrossRefGoogle Scholar
  16. 16.
    Nikitakis NG, Koumaki D. Laugier–Hunziker syndrome: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(1):e52–8.CrossRefGoogle Scholar
  17. 17.
    Rangwala S, Doherty CB, Katta R. Laugier–Hunziker syndrome: a case report and review of the literature. Dermatol Online J. 2010;16(12):9.Google Scholar
  18. 18.
    Wang WM, Wang X, Duan N, Jiang HL, Huang XF. Laugier–Hunziker syndrome: a report of three cases and literature review. Int J Oral Sci. 2012;4(4):226–30.CrossRefGoogle Scholar
  19. 19.
    Abduljabbar T, Vohra F, Akram Z, Ghani SMA, Al-Hamoudi N, Javed F. Efficacy of surgical laser therapy in the management of oral pigmented lesions: a systematic review. J Photochem Photobiol B. 2017;173:353–9.CrossRefGoogle Scholar
  20. 20.
    Tosios KI, Kalogirou EM, Sklavounou A. Drug-associated hyperpigmentation of the oral mucosa: report of four cases. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018;125(3):e54–66.CrossRefGoogle Scholar
  21. 21.
    Yuan A, Woo SB. Adverse drug events in the oral cavity. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119(1):35–47.CrossRefGoogle Scholar
  22. 22.
    Eisen D, Hakim MD. Minocycline-induced pigmentation. Incidence, prevention and management. Drug Saf. 1998;18(6):431–40.CrossRefGoogle Scholar
  23. 23.
    Lerman MA, Karimbux N, Guze KA, Woo SB. Pigmentation of the hard palate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(1):8–12.CrossRefGoogle Scholar
  24. 24.
    Treister NS, Magalnick D, Woo SB. Oral mucosal pigmentation secondary to minocycline therapy: report of two cases and a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(6):718–25.CrossRefGoogle Scholar
  25. 25.
    Kaugars GE, Heise AP, Riley WT, Abbey LM, Svirsky JA. Oral melanotic macules. A review of 353 cases. Oral Surg Oral Med Oral Pathol. 1993;76(1):59–61.CrossRefGoogle Scholar
  26. 26.
    Buchner A, Hansen LS. Melanotic macule of the oral mucosa. A clinicopathologic study of 105 cases. Oral Surg Oral Med Oral Pathol. 1979;48(3):244–9.CrossRefGoogle Scholar
  27. 27.
    Buchner A, Merrell PW, Carpenter WM. Relative frequency of solitary melanocytic lesions of the oral mucosa. J Oral Pathol Med. 2004;33(9):550–7.CrossRefGoogle Scholar
  28. 28.
    Shen ZY, Liu W, Bao ZX, Zhou ZT, Wang LZ. Oral melanotic macule and primary oral malignant melanoma: epidemiology, location involved, and clinical implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(1):e21–5.CrossRefGoogle Scholar
  29. 29.
    Gupta G, Williams RE, Mackie RM. The labial melanotic macule: a review of 79 cases. Br J Dermatol. 1997;136(5):772–5.CrossRefGoogle Scholar
  30. 30.
    Tavares TS, Meirelles DP, de Aguiar MCF, Caldeira PC. Pigmented lesions of the oral mucosa: a cross-sectional study of 458 histopathological specimens. Oral Dis. 2018. Scholar
  31. 31.
    Ho KK, Dervan P, O’Loughlin S, Powell FC. Labial melanotic macule: a clinical, histopathologic, and ultrastructural study. J Am Acad Dermatol. 1993;28(1):33–9.CrossRefGoogle Scholar
  32. 32.
    Weathers DR, Corio RL, Crawford BE, Giansanti JS, Page LR. The labial melanotic macule. Oral Surg Oral Med Oral Pathol. 1976;42(2):196–205.CrossRefGoogle Scholar
  33. 33.
    Page LR, Corio RL, Crawford BE, Giansanti JS, Weathers DR. The oral melanotic macule. Oral Surg Oral Med Oral Pathol. 1977;44(2):219–26.CrossRefGoogle Scholar
  34. 34.
    Sexton FM, Maize JC. Melanotic macules and melanoacanthomas of the lip. A comparative study with census of the basal melanocyte population. Am J Dermatopathol. 1987;9(5):438–44.CrossRefGoogle Scholar
  35. 35.
    Kauzman A, Pavone M, Blanas N, Bradley G. Pigmented lesions of the oral cavity: review, differential diagnosis, and case presentations. J Can Dent Assoc. 2004;70(10):682–3.Google Scholar
  36. 36.
    Lambertini M, Patrizi A, Ravaioli GM, Dika E. Oral pigmentation in physiologic conditions, post inflammatory affections and systemic diseases. G Ital Dermatol Venereol. 2017. Google Scholar
  37. 37.
    Uribe P, Collgros H, Scolyer RA, Menzies SW, Guitera P. In vivo reflectance confocal microscopy for the diagnosis of melanoma and melanotic macules of the lip. JAMA Dermatol. 2017;153(9):882–91.CrossRefGoogle Scholar
  38. 38.
    Hatch CL. Pigmented lesions of the oral cavity. Dent Clin N Am. 2005;49(1):185–201, ix–x.Google Scholar
  39. 39.
    Tarakji B, Umair A, Prasad D, Alsakran Altamimi M. Diagnosis of oral pigmentations and malignant transformations. Singap Dent J. 2014;35C:39–46.CrossRefGoogle Scholar
  40. 40.
    Gondak RO, da Silva-Jorge R, Jorge J, Lopes MA, Vargas PA. Oral pigmented lesions: clinicopathologic features and review of the literature. Med Oral Patol Oral Cir Bucal. 2012;17(6):e919–24.CrossRefGoogle Scholar
  41. 41.
    Rohilla K, Ramesh V, Balamurali P, Singh N. Oral melanoacanthoma of a rare intraoral site: case report and review of literature. Int J Clin Pediatr Dent. 2013;6(1):40–3.CrossRefGoogle Scholar
  42. 42.
    Peters SM, Mandel L, Perrino MA. Oral melanoacanthoma of the palate: an unusual presentation of an uncommon entity. JAAD Case Rep. 2018;4(2):138–9.Google Scholar
  43. 43.
    Cantudo-Sanagustin E, Gutierrez-Corrales A, Vigo-Martinez M, Serrera-Figallo MA, Torres-Lagares D, Gutierrez-Perez JL. Pathogenesis and clinicohistopathological characteristics of melanoacanthoma: a systematic review. J Clin Exp Dent. 2016;8(3):e327–36.Google Scholar
  44. 44.
    Hassona Y, Sawair F, Al-Karadsheh O, Scully C. Prevalence and clinical features of pigmented oral lesions. Int J Dermatol. 2016;55(9):1005–13.CrossRefGoogle Scholar
  45. 45.
    Mirbod SM, Ahing SI. Tobacco-associated lesions of the oral cavity: Part I. Nonmalignant lesions. J Can Dent Assoc. 2000;66(5):252–6.Google Scholar
  46. 46.
    Monteiro LS, Costa JA, da Camara MI, Albuquerque R, Martins M, Pacheco JJ, Salazar F, Figueira F. Aesthetic depigmentation of gingival smoker’s melanosis using carbon dioxide lasers. Case Rep Dent. 2015;2015:510589.Google Scholar
  47. 47.
    Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988–1994. J Am Dent Assoc. 2004;135(9):1279–86.CrossRefGoogle Scholar
  48. 48.
    Buchner A, Hansen LS. Amalgam pigmentation (amalgam tattoo) of the oral mucosa. A clinicopathologic study of 268 cases. Oral Surg Oral Med Oral Pathol. 1980;49(2):139–47.CrossRefGoogle Scholar
  49. 49.
    Owens BM, Schuman NJ, Johnson WW. Oral amalgam tattoos: a diagnostic study. Compendium 1993;14(2):210, 212, 214 passim.Google Scholar
  50. 50.
    Thumbigere-Math V, Johnson DK. Treatment of amalgam tattoo with a subepithelial connective tissue graft and acellular dermal matrix. J Int Acad Periodontol. 2014;16(2):50–4.Google Scholar
  51. 51.
    Avcu N, Kanli A. The prevalence of tongue lesions in 5150 Turkish dental outpatients. Oral Dis. 2003;9(4):188–95.CrossRefGoogle Scholar
  52. 52.
    Kullaa-Mikkonen A, Mikkonen M, Kotilainen R. Prevalence of different morphologic forms of the human tongue in young Finns. Oral Surg Oral Med Oral Pathol. 1982;53(2):152–6.CrossRefGoogle Scholar
  53. 53.
    Motallebnejad M, Babaee N, Sakhdari S, Tavasoli M. An epidemiologic study of tongue lesions in 1901 Iranian dental outpatients. J Contemp Dent Pract. 2008;9(7):73–80.Google Scholar
  54. 54.
    Redman RS. Prevalence of geographic tongue, fissured tongue, median rhomboid glossitis, and hairy tongue among 3,611 Minnesota schoolchildren. Oral Surg Oral Med Oral Pathol. 1970;30(3):390–5.CrossRefGoogle Scholar
  55. 55.
    Gurvits GE, Tan A. Black hairy tongue syndrome. World J Gastroenterol. 2014;20(31):10845–50.CrossRefGoogle Scholar
  56. 56.
    Mangold AR, Torgerson RR, Rogers III RS. Diseases of the tongue. Clin Dermatol. 2016;34(4):458–69.CrossRefGoogle Scholar
  57. 57.
    Schlager E, St Claire C, Ashack K, Khachemoune A. Black hairy tongue: predisposing factors, diagnosis, and treatment. Am J Clin Dermatol. 2017;18(4):563–9.CrossRefGoogle Scholar
  58. 58.
    Manabe M, Lim HW, Winzer M, Loomis CA. Architectural organization of filiform papillae in normal and black hairy tongue epithelium: dissection of differentiation pathways in a complex human epithelium according to their patterns of keratin expression. Arch Dermatol. 1999;135(2):177–81.CrossRefGoogle Scholar
  59. 59.
    Akcaboy M, Sahin S, Zorlu P, Senel S. Ranitidine-induced black tongue: a case report. Pediatr Dermatol. 2017;34(6):e334–6.CrossRefGoogle Scholar
  60. 60.
    Farinha H, Martins V. Lingua villosa nigra associated with the use of electronic cigarette. Acta Med Port. 2015; 28(3):393.CrossRefGoogle Scholar
  61. 61.
    Lawoyin D, Brown RS. Drug-induced black hairy tongue: diagnosis and management challenges. Dent Today 2008;27(1):60, 62, 3; quiz 93, 58.Google Scholar
  62. 62.
    Nisa L, Giger R. Black hairy tongue. Am J Med. 2011;124(9):816–7.CrossRefGoogle Scholar
  63. 63.
    Winzer M, Gilliar U, Ackerman AB. Hairy lesions of the oral cavity. Clinical and histopathologic differentiation of hairy leukoplakia from hairy tongue. Am J Dermatopathol. 1988;10(2):155–9.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Molly S. Rosebush
    • 1
    Email author
  • Ashleigh N. Briody
    • 2
  • Kitrina G. Cordell
    • 1
  1. 1.Louisiana State UniversityNew OrleansUSA
  2. 2.Central Ohio Skin & Cancer, Inc.WestervilleUSA

Personalised recommendations