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Amalgam tattoo

Hien T Tran MD PhD, Niroshana Anandasabapathy MD PhD,


Anthony C Soldano MD
Dermatology Online Journal 14 (5): 19

Department of Dermatology, New York University

Abstract

A 53-year-old woman with a history of melanoma status-post excision two years


prior presented with a 4-month history of 4 dark-brown macules on the inferior
surface of her tongue. A biopsy specimen showed a squamous mucosa with
chronic submucosal inflammation and brown pigment. The clinical and
histopathologic findings were consistent with a diagnosis of amalgam tattoo.
Amalgam tattoos are common, oral pigmented lesions that clinically present as
isolated, blue, grey, or black macules on the gingivae, the buccal and alveolar
mucosae, the palate, and/or the tongue. They are due to deposition of a mixture of
silver, tin, mercury, copper, and zinc, which are components of an amalgam filling,
into the oral soft tissues. Amalgam tattoos can either be treated surgically or with a
Q-switched ruby laser. In the case of our patient with the history of melanoma, her
oral lesions proved not to be the more dire diagnosis of malignant melanoma.

Clinical synopsis

A 53-year-old woman with a history of melanoma status-post excision 2 years


prior presented to the Dermatology Clinic at Bellevue Hospital Center with a 4-
month history of 4 dark-brown macules on the inferior surface of her tongue. The
patient reported that the lesions were non-painful, that they had never bled, and
that she had not suffered trauma to this area. The review of systems was
unremarkable. The patient also had also been seen in the Ear Nose and Throat
Clinic at Bellevue Hospital Center prior to being evaluated in the Dermatology
Clinic, where the pigmented lesions were thought to be varicosities. The lesions
were not biopsied at that time. The patient was not taking any medications but was
taking multivitamins.
The patient was refered to oral surgery for a biopsy of the pigmented macule on the
inferior surface of the tongue.
Physical Examination

Four dark-brown macules that measured 2- to 3-mm in size were present. The
largest was located to the right of the frenulum. Two additional lesions were
located on either side of the frenulum, and the fourth smaller lesion was located
postero-lateral to the most lateral right-sided lesion.

Figure 1 Figure 2
A complete blood count, metabolic panel, hepatic panel, and lipid panel were
normal.

Histopathology

In the lamina propria there is a finely granular black/brown pigment that encases
elastic fibers and the basement membrane of superficial capillaries; it is within the
cytoplasm of histiocytes.

Comment

Amalgam tattoos are common oral pigmented lesions that clinically present as
isolated, blue, grey, or black macules on the gingivae, the buccal and alveolar
mucosae, the palate, and/or the tongue. They are due to deposition of a mixture of
silver, tin, mercury, copper, and zinc, which are components of an amalgam filling,
into the oral soft tissues [1, 2, 3]. The deposition occurs after a number of different
dental procedures that include diffusion through soft tissues from root-end fillings,
accidental deposition of fine metallic particles into the gingiva by high-speed
drills, accidental abrasion of the mucosa by high-speed rotary instruments, or
deposition of amalgam scraps left behind during extraction [4, 6].
These tattoos do not represent a health hazard since the mercury present in
amalgam is not in a free state [5, 6]. However, owing to its clinical appearance,
amalgam tattoos can be mistaken for a number of different conditions of concern,
such as melanoma, pigment-cell nevi, melanotic macules, melanoacanthoma,
Kaposi's sarcoma, and physiologic pigmentation [7]. The diagnosis is more easily
determined if the lesion is in the vicinity of a large silver amalgam restoration or a
gold crown. If not, a biopsy may be performed. Histopathologic features include
discrete, fine, dark granules and irregular, solid fragments. They can be found
along collagen bundles and vessels and also are found within macrophages,
mulinucleated giant cells, fibroblasts, and endothelial cells [8].
Treatment for amalgam tattoos was originally limited to surgery with grafting of
mucosa or gingiva over the previous site of the tattoo [9, 10]. Advances in laser
technology now allow amalgam tattoos to be removed by the Q-switched ruby
laser [5, 6]. It is believed that the lasers shatter the tattoo particles that are then
removed by the lymphatics or transepidermal extrusion.

References

1. Weathers DR, Fine RM. Amalgam tattoo of the oral mucosa. Arch Dermatol
1974; 110:727

2. Mirowski GW, Waibel JS. Pigmented lesions of the oral cavity. Dermatol Ther
2002; 15: 218

3. 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; 49:139

4. Pigatto PD, et al. Amalgam tattoo: a close-up view. J Eur Acad Dermatol
Venereol 2006; 20:1352

5. Ashinoff R, Tanenbaum D. Treatment of an amalgam tattoo with the Q-switched


ruby laser. Cutis 1994; 54:269

6. Shah G, Alster TS. Treatment of an amalgam tattoo with a Q-switched


Alexandrite (755 nm) laser. Dermatol Surg 2002; 28:1180

7. Martin JM, et al. An amalgam tattoo on the oral mucosa related to a dental
prosthesis. J Eur Acad Dermatol Venereol 2005; 19:90

8. McGinnis JP, et al. Amalgam tattoo: report of an unusual clinical presentation


and the use of energy dispersive x-ray analyses as an aid to diagnosis. J Am Dent
Assoc 1985; 110:52

9. Dello-Russo NM. Esthetic use of a free gingival autograft to cover an amalgam


tattoo: report of a case. J Am Dent Assoc 1981; 102:334

10. Shiloah J, et al. Reconstructive mucogingival surgery: the management of


amalgam tattoo. Quintess Int 1988; 19:489

© 2008 Dermatology Online Journal


Tato Amalgam

Hien T Tran MD PhD, Niroshana Anandasabapathy MD PhD, Anthony C Soldano MD

Jurnal Dermatologi Online 14 (5): 19

Departemen Dermatologi, Universitas New York

Abstrak

Seorang wanita berusia 53 tahun dengan riwayat melanoma status-post excision dua tahun
sebelumnya disajikan dengan riwayat 4 bulan dari 4 makula coklat gelap di permukaan
lidahnya yang inferior. Spesimen biopsi menunjukkan mukosa skuamosa dengan
peradangan submukosa kronis dan pigmen coklat. Temuan klinis dan histopatologis
konsisten dengan diagnosis tato amalgam. Tato Amalgam umum terjadi, lesi berpigmen oral
yang secara klinis hadir sebagai makula terisolasi, biru, abu-abu, atau hitam pada gingiva,
mukosa bukal dan alveolar, langit-langit mulut, dan / atau lidah. Mereka disebabkan oleh
pengendapan campuran perak, timah, merkuri, tembaga, dan seng, yang merupakan
komponen pengisian amalgam, ke dalam jaringan lunak oral. Tato Amalgam dapat diobati
dengan operasi atau dengan laser ruby Q-switched. Dalam kasus pasien kami dengan
riwayat melanoma, lesi lisannya terbukti tidak menjadi diagnosis yang lebih mengerikan dari
melanoma ganas.

Sinopsis klinis

Seorang wanita berusia 53 tahun dengan riwayat melanoma status-post eksisi 2 tahun
sebelumnya dipresentasikan ke Klinik Dermatologi di Pusat Rumah Sakit Bellevue dengan
riwayat 4 bulan dari 4 makula coklat gelap di permukaan lidahnya yang inferior. Pasien
melaporkan bahwa lesi itu tidak menyakitkan, bahwa mereka tidak pernah berdarah, dan
bahwa dia tidak mengalami trauma pada area ini. Kaji ulang sistem itu biasa-biasa saja.
Pasien juga pernah terlihat di Klinik Telinga Hidung dan Tenggorokan di Pusat Rumah Sakit
Bellevue sebelum dievaluasi di Dermatology Clinic, di mana lesi berpigmen dianggap
varicositas. Lesi tidak dibiopsi pada saat itu. Pasien tidak minum obat apapun tapi
mengkonsumsi multivitamin.

Pasien diacu pada operasi lisan untuk biopsi makula berpigmen pada permukaan inferior
lidah.

Pemeriksaan fisik
Empat makula coklat gelap yang berukuran 2 sampai 3 mm ada. Yang terbesar terletak di
sebelah kanan frenulum. Dua lesi tambahan terletak di kedua sisi frenulum, dan lesi kecil
keempat terletak postero-lateral ke lesi sisi kanan paling lateral.

Gambar 1 Gambar 2

Jumlah darah lengkap, panel metabolik, panel hati, dan panel lipid normal.

Histopatologi

Dalam lamina propria ada pigmen hitam / coklat halus yang menutupi serat elastis dan
membran basal kapiler superfisial; itu berada di dalam sitoplasma histiosit.

Komentar

Tato Amalgam adalah lesi berpigmen oral yang umum yang hadir secara klinis sebagai
makula terisolasi, biru, abu-abu atau hitam pada gingiva, mukosa bukal dan alveolar, langit-
langit mulut, dan / atau lidah. Mereka disebabkan oleh pengendapan campuran perak,
timah, merkuri, tembaga, dan seng, yang merupakan komponen pengisian amalgam, ke
dalam jaringan lunak oral [1, 2, 3]. Deposisi terjadi setelah sejumlah prosedur gigi yang
berbeda yang mencakup difusi melalui jaringan lunak dari tambalan akar-ujung,
pengendapan kebetulan partikel logam halus ke dalam gingiva dengan latihan berkecepatan
tinggi, abrasi mukosa sengaja oleh instrumen putar berkecepatan tinggi, atau deposisi
potongan amalgam tertinggal selama ekstraksi [4, 6].

Tato ini tidak mewakili bahaya kesehatan karena merkuri yang ada dalam amalgam tidak
berada dalam keadaan bebas [5, 6]. Namun, karena penampilan klinisnya, tato amalgam
dapat disalahartikan untuk sejumlah kondisi kekhawatiran yang berbeda, seperti melanoma,
nevi sel pigmen, makula melanotik, melanoakanthoma, sarkoma Kaposi, dan pigmentasi
fisiologis [7]. Diagnosis lebih mudah ditentukan jika lesi berada di sekitar restorasi amalgam
perak besar atau mahkota emas. Jika tidak, biopsi bisa dilakukan. Fitur histopatologis
meliputi butiran gelap, halus, gelap, dan fragmen padat yang tidak beraturan. Mereka dapat
ditemukan di sepanjang bundel dan pembuluh darah kolagen dan juga ditemukan di dalam
makrofag, sel raksasa mulinucleated, fibroblas, dan sel endotel [8].

Pengobatan untuk tato amalgam pada mulanya terbatas pada operasi dengan mencangkok
mukosa atau gingiva dari situs sebelumnya dari tato [9, 10]. Kemajuan teknologi laser
sekarang memungkinkan tato amalgam dilepas oleh laser ruby Q-switched [5, 6]. Hal ini
diyakini bahwa laser menghancurkan partikel tato yang kemudian dikeluarkan oleh limfatik
atau ekstrusi transepidermal.

Referensi