History

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

Physical Examination

Smoker's melanosis is a brownish discoloration of the oral mucosa. The process affects most often the anterior facial gingiva of both jaws, but with a predilection for the mandible. Pipe smokers more frequently display pigmentation of the commissural and buccal mucosae.^[5]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, suggesting that melanin might have a protective role against noxious substances in the tobacco smoke.^[22]

Haresaku et al found both gingival and lip pigmentation to be strongly associated with smoking.

In a Nigerian study, the buccal mucosa was the most frequently pigmented site in smokers.^[9]

See the images below.

Several focal brownish pigmentations of the maxillary anterior gingiva.

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

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Differential Diagnoses

Hedin CA. Smokers' melanosis. Occurrence and localization in the attached gingiva. Arch Dermatol. 1977 Nov. 113(11):1533-8. [QxMD MEDLINE Link].
Yerger VB, Malone RE. Melanin and nicotine: A review of the literature. Nicotine Tob Res. 2006 Aug. 8 (4):487-98. [QxMD MEDLINE Link].
Roberto A, Larsson BS, Tjälve H. Uptake of 7,12-dimethylbenz(a)anthracene and benzo(a)pyrene in melanin-containing tissues. Pharmacol Toxicol. 1996 Aug. 79 (2):92-9. [QxMD MEDLINE Link].
Claffey DJ, Stout PR, Ruth JA. 3H-nicotine, 3H-flunitrazepam, and 3H-cocaine incorporation into melanin: a model for the examination of drug-melanin interactions. J Anal Toxicol. 2001 Oct. 25 (7):607-11. [QxMD MEDLINE Link].
Axéll T, Hedin CA. Epidemiologic study of excessive oral melanin pigmentation with special reference to the influence of tobacco habits. Scand J Dent Res. 1982 Dec. 90(6):434-42. [QxMD MEDLINE Link].
Haresaku S, Hanioka T, Tsutsui A, Watanabe T. Association of lip pigmentation with smoking and gingival melanin pigmentation. Oral Dis. 2007 Jan. 13 (1):71-6. [QxMD MEDLINE Link].
Abdel Moneim RA, Deeb ME, Rabea AA. Gingival pigmentation (cause, treatment and histological preview). ScienceDirect. Available at https://www.sciencedirect.com/science/article/pii/S231471801630074X. June 2017; Accessed: June 19, 2018.
Hedin CA, Axéll T. Oral melanin pigmentation in 467 Thai and Malaysian people with special emphasis on smoker's melanosis. J Oral Pathol Med. 1991 Jan. 20(1):8-12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mehrotra R, Thomas S, Nair P, Pandya S, Singh M, Nigam NS, et al. Prevalence of oral soft tissue lesions in Vidisha. BMC Res Notes. 2010 Jan 25. 3:23. [QxMD MEDLINE Link]. [Full Text].
Sridharan G. Epidemiology, control and prevention of tobacco induced oral mucosal lesions in India. Indian J Cancer. 2014 Jan-Mar. 51(1):80-5. [QxMD MEDLINE Link].
Patil PB, Bathi R, Chaudhari S. Prevalence of oral mucosal lesions in dental patients with tobacco smoking, chewing, and mixed habits: A cross-sectional study in South India. J Family Community Med. 2013 May. 20(2):130-5. [QxMD MEDLINE Link]. [Full Text].
Ahmadi-Motamayel F, Falsafi P, Hayati Z, Rezaei F, Poorolajal J. Prevalence of oral mucosal lesions in male smokers and nonsmokers. Chonnam Med J. 2013 Aug. 49(2):65-8. [QxMD MEDLINE Link]. [Full Text].
Al-Attas SA, Ibrahim SS, Amer HA, Darwish Zel-S, Hassan MH. Prevalence of potentially malignant oral mucosal lesions among tobacco users in Jeddah, Saudi Arabia. Asian Pac J Cancer Prev. 2014. 15(2):757-62. [QxMD MEDLINE Link].
Hanioka T, Tanaka K, Ojima M, Yuuki K. Association of melanin pigmentation in the gingiva of children with parents who smoke. Pediatrics. 2005 Aug. 116 (2):e186-90. [QxMD MEDLINE Link].
Sridharan S, Ganiger K, Satyanarayana A, Rahul A, Shetty S. Effect of environmental tobacco smoke from smoker parents on gingival pigmentation in children and young adults: a cross-sectional study. J Periodontol. 2011 Jul. 82 (7):956-62. [QxMD MEDLINE Link].
Hajifattahi F, Azarshab M, Haghgoo R, Lesan S. Evaluation of the Relationship between Passive Smoking and Oral Pigmentation in Children. J Dent (Tehran). 2010 Summer. 7 (3):119-23. [QxMD MEDLINE Link].
Moravej-Salehi E, Moravej-Salehi E, Hajifattahi F. Relationship of Gingival Pigmentation with Passive Smoking in Women. Tanaffos. 2015. 14 (2):107-14. [QxMD MEDLINE Link].
Natale CA, Duperret EK, Zhang J, Sadeghi R, Dahal A, O'Brien KT, et al. Sex steroids regulate skin pigmentation through nonclassical membrane-bound receptors. Elife. 2016 Apr 26. 5:[QxMD MEDLINE Link].
Grimes PE. Melasma. Etiologic and therapeutic considerations. Arch Dermatol. 1995 Dec. 131 (12):1453-7. [QxMD MEDLINE Link].
Hedin C, Pindborg JJ, Daftary DK, Mehta FS. Melanin depigmentation of the palatal mucosa in reverse smokers: a preliminary study. J Oral Pathol Med. 1992 Nov. 21(10):440-4. [QxMD MEDLINE Link].
Chi A, Neville B, Damm D, Allen C. Smoker's Melanosis. Chi A, Neville B, Damm D, Allen C. eds. Oral & Maxillofacial Pathology. 4th ed. St. Louis, Mo: WB Saunders; 2016. 289-90.
Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016 Mar 24. 3:CD008286. [QxMD MEDLINE Link].
Hedin CA, Pindborg JJ, Axéll T. Disappearance of smoker's melanosis after reducing smoking. J Oral Pathol Med. 1993 May. 22(5):228-30. [QxMD MEDLINE Link].
Zarate AM, Brezzo MM, Secchi DG, Barra JL, Brunotto M. Malignancy risk models for oral lesions. Med Oral Patol Oral Cir Bucal. 2013 Sep 1. 18(5):e759-65. [QxMD MEDLINE Link]. [Full Text].
Kato T, Takiuchi H, Sugiyama S, Makino M, Noguchi S, Katayama-Ono T, et al. Measurement of Reduced Gingival Melanosis after Smoking Cessation: A Novel Analysis of Gingival Pigmentation Using Clinical Oral Photographs. Int J Environ Res Public Health. 2016 Jun 16. 13 (6):[QxMD MEDLINE Link].
Monteiro LS, Costa JA, da Câmara MI, Albuquerque R, Martins M, Pacheco JJ, et al. Aesthetic Depigmentation of Gingival Smoker's Melanosis Using Carbon Dioxide Lasers. Case Rep Dent. 2015. 2015:510589. [QxMD MEDLINE Link].
[Guideline] US Preventive Services Task Force. Final Recommendation Statement: Tobacco Use in Adults and Pregnant Women: Counseling and Interventions. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions. Accessed: January 26, 2015.

Media Gallery

Several focal brownish pigmentations of the maxillary anterior gingiva.
Gingival biopsy of a basilar melanosis (a brownish granular pigment present along the basal cells).
A reverse smoker with white and pigmented palatal mucosa and a focal area of erythema.

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Author

Leticia Ferreira, DDS, MS Associate Professor, Department of Diagnostic Sciences, University of the Pacific, Arthur A Dugoni School of Dentistry

Leticia Ferreira, DDS, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Association of Women Dentists, American Dental Association, American Dental Education Association, California Dental Association, San Francisco Dental Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster 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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

Jeff Burgess, DDS, MSD (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates

Disclosure: Nothing to disclose.

Additional Contributors

R Stan Taylor, MD The JB Howell Professor in Melanoma Education and Detection, Departments of Dermatology and Plastic Surgery, Director, Skin Surgery and Oncology Clinic, 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 Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

Dana Gelman Keiles, DMD Assistant Clinical Professor, Department of Stomatology, University of California at San Francisco

Dana Gelman Keiles, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association

Disclosure: Nothing to disclose.