eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Smoker's Melanosis

William M Carpenter, DDS, MS, Professor, Chairman, Department of Pathology and Medicine, University of the Pacific Arthur A Dugoni School of Dentistry

Updated: Oct 6, 2009

Introduction

Background

The main etiologic factor responsible for melanocytic pigmentation of the oral mucosa in the white population is cigarette smoking. In his 1977 report, Hedin¹ coined the term smoker's melanosis to describe this clinical condition.

Pathophysiology

Smoker's melanosis may be due to the effects of nicotine (a polycyclic compound) on melanocytes located along the basal cells of the lining epithelium of the oral mucosa. Nicotine appears to directly stimulate melanocytes to produce more melanosomes, which results in increased deposition of melanin pigment as basilar melanosis with varying amounts of melanin incontinence.

Frequency

United States

No prevalence studies on smoker's melanosis are available in the United States.

International

In a Swedish study of 31,000 whites, 21.5% of tobacco smokers exhibited smoker's melanosis, whereas only 3% of nonsmokers had the lesion.² In a study of Thai subjects and Malaysian subjects, nearly all had physiologic pigmentation, but tobacco users had significantly more oral surfaces displaying pigmentation.³ A Nigerian study reported a prevalence of 52% of pigmented sites in nonsmokers and 6% among smokers. The buccal mucosa was the most common site for smoker's melanosis.⁴

Mortality/Morbidity

Smoker's melanosis is not associated with mortality or morbidity.

Race

Smoker's melanosis is most evident in whites because of a lack of physiologic pigmentation in the oral mucosa of this population, but some dark-skinned individuals who smoke will have more prominent pigmentation in many oral sites. A study of Turkish Army recruits revealed gingival pigmentation in 27.5% of smokers and 8.6% of those who never smoked.⁵

Sex

Females are affected by smoker's melanosis more than males, which may be explained by the additive effects of estrogen in female smokers. Increases in estrogen levels observed during pregnancy and the use of birth control pills are linked to other hyperpigmentation conditions (eg, melasma).

Age

The incidence of smoker's melanosis increases with age, suggesting that the longer a person smokes, the more likely he or she will develop the condition.⁶

Clinical

History

No symptoms are associated with smoker's melanosis. A smoking history is needed to substantiate the diagnosis.

Physical

Smoker's melanosis is a brownish discoloration of the oral mucosa. In cigarette smokers, most lesions are located on the mandibular anterior gingiva. Pipe smokers more frequently display pigmentation of the buccal mucosa. In people who engage in reverse smoking (ie, the lit end of a cigarette placed in the oral cavity), pigmentation of the hard palate is common. If the areas become depigmented and erythematous, squamous cell carcinoma has been found in 12% of these patients.⁷

Several focal brownish pigmentations of the maxillary anterior gingiva.

A reverse smoker with white and pigmented palatal mucosa and a focal area of erythema.

Causes

Smoker's melanosis is likely due to direct effects of tobacco smoke on the oral mucosa. Smoke is thought to cause changes in the mucosa through a combination of physical (heat) and/or chemical (nicotine) effects. Individuals using smokeless tobacco or nicotine-containing gum do not develop this condition. Also see Cutaneous Manifestations of Smoking and Smokeless Tobacco Lesions.

Differential Diagnoses

Addison Disease
Albright Syndrome
Hemochromatosis
Neurofibromatosis
Oral Malignant Melanoma
Oral Nevi

Workup

Laboratory Studies

Generally, no laboratory studies are necessary to confirm the diagnosis of smoker's melanosis; clinical impression is usually sufficient, in combination with a history of smoking.

Procedures

If the pigmentation is localized, an ulceration is present or the lesion is elevated, a biopsy is necessary to exclude other pigmented conditions (eg, nevi, melanoma). Although smoker's melanosis is an abnormal deposition of melanin, the lesion itself is not associated with an increased risk of melanoma or carcinoma.

Histologic Findings

Basilar melanosis, with or without melanin incontinence, is observed.

Gingival biopsy of a basilar melanosis (a brownish granular pigment present along the basal cells).

Treatment

Medical Care

Smoking cessation is indicated for a multitude of health reasons. Cessation usually results in gradual disappearance of the melanosis over a period of several years.⁸

Consultations

Smoking cessation programs with counselors or behavior modification specialists may be beneficial. Also see the clinical guideline summary from the US Preventive Services Task Force, Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement.⁹

Follow-up

Further Outpatient Care

Routine follow-up care is necessary to ensure that the lesion is slowly disappearing.

Prognosis

The prognosis of a patient with smoker's melanosis is excellent.

Patient Education

Educate this patient population concerning the deleterious health effects of smoking. For excellent patient education resources, visit eMedicine's Public Health Center and Lung and Airway Center. Also, see eMedicine's patient education article Cigarette Smoking.

Miscellaneous

Medicolegal Pitfalls

Potentially, failure to properly educate patients regarding the deleterious effects of smoking

Multimedia

Media file 1: Several focal brownish pigmentations of the maxillary anterior gingiva.

Media file 2: Gingival biopsy of a basilar melanosis (a brownish granular pigment present along the basal cells).

Media file 3: A reverse smoker with white and pigmented palatal mucosa and a focal area of erythema.

References

Hedin CA. Smokers' melanosis. Occurrence and localization in the attached gingiva. Arch Dermatol. Nov 1977;113(11):1533-8. [Medline].
Axéll T, Hedin CA. Epidemiologic study of excessive oral melanin pigmentation with special reference to the influence of tobacco habits. Scand J Dent Res. Dec 1982;90(6):434-42. [Medline].
Hedin CA, Axéll T. Oral melanin pigmentation in 467 Thai and Malaysian people with special emphasis on smoker's melanosis. J Oral Pathol Med. Jan 1991;20(1):8-12. [Medline].
Nwhator SO, Winfunke-Savage K, Ayanbadejo P, Jeboda SO. Smokers' melanosis in a Nigerian population: a preliminary study. J Contemp Dent. Pract. Jul 2007;8(5):68-75. [Medline].
Marakoglu K, Gursoy, UK, Toker, HC, Demirer S, et al. Smoking status and smoke-related gingival melanin pigmentation in army recruitments. Mil Med. Jan 2007;172:110-3. [Medline].
Brown FH, Houston GD. Smoker's melanosis. A case report. J Periodontol. Aug 1991;62(8):524-7. [Medline].
Hedin C, Pindborg JJ, Daftary DK, Mehta FS. Melanin depigmentation of the palatal mucosa in reverse smokers: a preliminary study. J Oral Pathol Med. Nov 1992;21(10):440-4. [Medline].
Hedin CA, Pindborg JJ, Axéll T. Disappearance of smoker's melanosis after reducing smoking. J Oral Pathol Med. May 1993;22(5):228-30. [Medline].
[Guideline] US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. Apr 21 2009;150(8):551-5. [Medline].
Neville BW. Smoker's Melanosis. In: Neville BW, Damm DD, Allen CM, and Bouquot JE, eds. Oral & Maxillofacial Pathology. 3^rd ed. Philadelphia, Pa: WB Saunders; 2002:316-17.
Taybos G. Oral changes associated with tobacco use. Am J Med Sci. Oct 2003;326(4):179-82. [Medline].

Keywords

smoker's melanosis, smoker melanosis, basilar melanosis, nicotine, smoking, tobacco, tobacco smoking, reverse smoking, pipe smoking, smokers, cigarette smokers, pipe smokers, reverse smokers, polycyclic compounds, melasma, hyperpigmentation, nevi, melanoma, Peutz-Jeghers syndrome

Contributor Information and Disclosures

Author

William M Carpenter, DDS, MS, Professor, Chairman, Department of Pathology and Medicine, University of the Pacific Arthur A Dugoni School of Dentistry
William M Carpenter, DDS, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology and American Academy of Oral Medicine
Disclosure: Nothing to disclose.

Medical Editor

R Stan Taylor, MD, Professor of Dermatology, University of Texas Southwestern Medical School; Director of Skin Surgery and Oncology Clinic, Department of Dermatology, University of Texas Southwestern Medical Center
R Stan Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Dana Gelman Keiles, DMD, and previous Chief Editor, William D. James, MD, to the development and writing of this article.

Further Reading