HEAVY METAL

PIGMENTATION

Presented by: Annissaqiella Maharani, drg

Oral Medicine Specialistic Degree Program IPMTL K 1
Faculty of Dental Medicine, Airlangga University 1
 DEFINITIO
Heavy metal deposition is a rare phenomenon
in the oral mucosa, it can be pigmentation in
oral mucosa because of ingestion of metal

It is caused by ingestion or exposure or

implantation of silver, lead, bismuth,
mercury, graphite, and other heavy metals.
2
 EPIDEMIOLOGY
• this phenomenon is rarely encountered
• it remains an occupational and health hazard for some individuals who work in
certain industrial plants (leadoxide batteries, the cable industry) and for those
who live around these types of facilities. Other relatively common
environmental sources include paints, old plumbing, pesticides, household
appliances, fuel and seafood

- the prevalence of lead poisoning (plumbism), but lead is one of the most widespread
environmental toxins affecting children in the United States (age 1-3 y.o)
- Prevalence of lead exposure through saliva at fuel station Indonesian officers 67%, male
and 21-30 y.o (Pasiga et al, 2019)
- Amalgam tattoos affect approximately 1–3% of the general population. (Glick et al., 2021)

3
 ETIOLOGY
It is caused by ingestion or exposure or
implantation of silver, lead, bismuth,
mercury, graphite, and other heavy metals.

Oral alterations from ingestion of lead, mercury, silver, bismuth,

arsenic, and gold may occur and warrant discussion.
Oral complications from excessive zinc, iron, tin, and manganese
are extremely rare.
4
LEAD/ plumbum (Pb)
- children may ingest chips of the paint in older homes or be exposed
to the fumes or dust during sanding and renovation.
• Adult exposure also occurs and often is related to industry. The
potential for exposure exists during handling of lead oxide batteries,
in lead-processing industries, and from the welding of lead-covered
surface.
• Lead also can be found in brass fixtures, ceramics, crystal, electrical
cable, radiation shielding, folk remedies, gasoline and cosmetics.

5
Mercury (Hg)
• inhalation of mercury vapor is very
hazardous, with a high rate of absorption
and systemic retention.
• Exposure has occurred in association with
the use of mercury in baby powders,
diapers, seafood, thermometer mercury
and anthelmintic preparations.
Investigators also have implicated
thimerosal, an ethyl mercury antiseptic
utilized in some vaccinations.
• Implantation of dental amalgam into
the oral mucosa during dental procedures
Silver (Ag)
• Silver has known antibacterial
properties and has been associated with a
number of additional health benefits. (nose
drop and systematically)
• health food stores as essential mineral
supplements for diseases such as
arthritis, cancer, diabetes.
• generalized argyria have been seen
secondary to long-term treatment of
aphthous ulcerations, denture sores, and
minor gingival hemorrhage with topical
silver nitrate
6
Bismuth (Bi)
• Bismuth was used in the past for treatment
of venereal diseases and various
dermatoses
• Bismuth iodoform paraffin paste continues
to be used by otolaryngologists and oral
surgeons as a surgical pack, with rare
reports of associated toxicity.
• bismuth subsalicylate tablets (Pepto-
Bismol) have been reported to produce
localized mucosal discoloration
Arsenic (As)
• Arsenic compounds were
prescribed for asthma and
skin disorders, such as
psoriasis.
• Chronic exposure to arsenic
continues in some lesser
developed areas of the world
from drinking contaminated
water.
7
Gold (Au)
• medical treatment in the past
and continues to be used today
in selected cases of active
rheumatoid arthritis and
other immunologically
mediated diseases.
• increased prevalence in patients
who have gold dental
restorations.
8
ETIOPATHOGENESIS

The attack of heavy

metals on a cell and
the balance between
ROS production and
the subsequent defense
presented by
antioxidants.(Ahmad
Bhat et al., 2019)

9
ETIOPATHOGEN
ESIS

Oxidative stress and organ toxicity

following exposure to heavy
metals. (Balali-Mood et al., 2021)

10
11
 SUBJECTIVE EXAMINATION
DIAGNOSIS
- Patients usually complain of a metallic taste and a
burning sensation on the mucosa.
- Family history can also show a similar complaint if the
heavy metal comes from the place of residence.
- Patients usually complain of malaise, abdominal
spasms, nausea, arthralgia, fever and insomnia

12
 OBJECTIVE EXAMINATION
• in the oral cavity, the pigmentation is usually
found along the free marginal gingiva, where it
often dramatically outlines the gingival cuff. This
DIAGNOSIS metallic line usually has a gray to black
appearance. In some patients, the oral
pigmentation may be the first sign of heavy metal
toxicity.
• Additional systemic signs and symptoms of heavy
metal poisoning may include behavioral changes,
neurologic disorders, intestinal pain, headache,
vertigo, insomnia, and sialorrhea.
13
 Lead Poisoning
• acute cases most often have abdominal colic, which may occur along with anemia, fatigue,
irritability, and weakness. Encephalopathy and renal dysfunction also may occur.
• Chronic exposure causes dysfunction of the nervous system, kidneys, marrow, bone, and
joints. Symptoms generally include fatigue, musculoskeletal pain, and headache
• Bones and teeth represent a major reservoir in patients with chronic plumbism.

Oral manifestations include ulcerative stomatitis and a gingival lead line

(Burton line). The lead line appears as a bluish line along the marginal
gingiva resulting from the action of bacterial hydrogen sulfide on lead in the
gingival sulcus to produce a precipitate of lead sulfide. Gray areas also may
be noted on the buccal mucosa and tongue.

14
 Lead line (Odell, 2017)

Lead pigmentation at margin gingival (Regezi et al., 2016)

Blue-black lead deposition on the marginal gingiva(Laskaris,

2019) 15
 Bismuth Poisoning
• Systemic bismuth toxicity presents with confusion, encephalopathy, hepatorenal impairment, and
methemoglobinemia.
• Chronic bismuth exposure also can result in a diffuse blue-gray discoloration of the skin,
conjunctivae, or oral cavity. A blue-gray line along the gingival margin similar to that seen from
lead intoxication is the most common intraoral presentation. Associated ptyalism, burning,
stomatitis, and ulceration may be seen
Symptoms—patients often complain of a metallic taste, increase salivation with burning sensation
in the oral cavity
• Ulcerative gingivostomatitis—
• Sign—large, extremely painful, shallow ulcerations are seen at times on the cheek mucosa in
molar region. Regional lymphadenopathy may be present.
• Tongue—tongue is frequently enlarged and sore.
• Bismuth line—‘blue black’ bismuth line appears to be well demarcated to eye on gingival
papillae. Blue black bismuth sulfide granules formed by action of H2S produced by action of
bacteria on organic materialremaining in areas of poor oral hygiene.
16
Blue-black linear bismuth deposition (Laskaris, 2019)
17
 Mercury Poisoning
• It is also called ‘Pink disease’, ‘Swift’s disease’, ‘Dermatopolyneuritis’, and ‘Acrodynia’
• GI symptom: diarrhea, intestinal colic, pharyngitis, dysphagia, nausea, abdominal pain
• Nervous symptom : headache, insomnia, tremors of fingers, mental depression
• hands, feet, nose and cheeks assume pink color
• the nails are shed at the same time with teeth lost prematurely and alopecia
• Raw beef appearance—the skin of hands, feet, nose, ears and cheek becomes clammy red or pink and has a cold clammy feeling.

Symptoms—. Patient may experience itching sensation and metallic taste in the oral cavity.
Mastication is difficult due to pain.
• Gingiva—the gingiva becomes extremely sensitive or painful and it may exhibit ulceration. The
gingiva may become blue gray to black in color
• Ulcerative stomatitis—oral mucosal ulceration occurs and spreads to the palate, throat and
pharynx.
• Salivary gland and lymph nodes—salivary glands and lymph nodes may be swollen.
• Tongue—tongue is enlarged, painful and ulcerated. Tongue tremors may be present.
• Lips—lips are dry, cracked and swollen. 18
(Glick et al., 2021) (DeLong and Burkhart, 2013)

19
 Silver Poisoning
• It is also called as ‘argyrosis’ which occurs due to chronic exposure to silver compound.
• Skin—skin is slate gray, violet or cyanotic and in marked cases, there is even suggestion
of metallic luster.
• • Nails—nails are also deeply pigmented.

Site—pigmentation is distributed diffusely throughout the gingival

and mucosal tissue.
• Color of gingiva—there is slate blue silver line along the gingival
margins.
• Oral mucosa—oral mucosa exhibits a diffuse bluish black
discoloration.
20
 Heavy silver pigmentation (Langlais et al., 2017)

Silver deposition (silver cone endodontic ) (Laskaris,

2019)

Grayish discoloration of the face compared with a more normal facial

complexion in an individual who used a silvercontaining nutritional
supplement. (Neville, 2019) 21
 Arsenic Poisoning
• Symptoms—chronic gastritis and colitis, keratosis of palms of the hand and soles of feet.
• Hyperpigmentation—diffuse macular hyperpigmentation is seen on the skin of the patient.
• Arsenical keratosis—these are the premalignant skin lesion which can occur in arsenic
poisoning.

Symptoms—extremely painful and patient may complain of excessive salivation.

Severe gingivitis—gingiva become intensely inflamed
Necrotizing ulcerative stomatitis—local contact with arsenic trioxide often produces
ulceration which can become necrotic.
Dorsal hyperkeratosis of tongue—this occurs in patient in past, who has taken
arsenic for syphilis treatment.
• Color of pigmentation—tissues are deep red in color.
22
 SUPPORTIVE EXAMINATION
Normal levels of metals in
the blood include
-lead (10 ug/dL)
-bismuth (0.05 – 0.1 ug/mL)
-mercury (10 ug/L)
-silver (0.1 – 20 ug/L)
-arsenic (0.3 -2 g/L) and
-gold (0.2 mg).
urine analysis which will
show levels of
- lead (1.92 mg/L)
- bismuth (150 - 1250 g/L),
- mercury (100 ug/L),
- silver (2.5 g/L),
- arsenic (0-35 g/L).
23
DIFFERENTIAL DIAGNOSIS
Physiological Pigmentation
Clinical Intraoral pigmentation more
appearance common in those with dark skin
so it is often referred to as racial
pigmentation. Pigmentation is
diffuse, like a well-defined dark
band with linear boundaries.
Amalgam tattoo
it is described as a flat macule
or sometimes slightly raised
lesion, solitary or multiple, well
defined or diffuse in other,
blue black in color
24
Racial or physiological pigmentation in gingiva margin
(Odell, 2017)

Amalgam Tattoo(Neville et al., 2019)

25
 COMPREHENSIVE TREATMENT
• Treatment for heavy metal poisoning includes elimination of
exposure to the causative agent, supportive care,
decontamination, and use of chelating agents.

Management of Bismutishm
• Removal of cause—Stoppage of use of bismuth.
• Oral hygiene maintenance
• Topical anesthetics—management of painful ulcerative
lesions should be done by topical application of lignocaine
hydrochloride gel. Or The 2% lidocaine gel

Management of Lead Poisoning

Chelating Agent :Dimercaprol, also known as British Anti-Lewisite
(BAL), Calcium Disodium ethylenediaminetetraacetate (EDTA), and
Succimer
26
Management Of Arsenism
• Anesthetic ointment—surface anesthetic ointment or
rinse such as lidocaine can be given to control
pain
• Chelating agents

Management of silver poisoning

• Removal of cause—source of contact should be
eliminated.
Management of mercury poisoning
• Supportive measure—bed rest and suitable dietary
regimen should be adjusted for renal damage.
• Control of salivary flow
Chelating agnet
27
 PROGNOSIS
Some are harmless accumulations of exogenous metals, while
others may signal a life threatening medical condition requiring
urgent intervention

The prognosis is generally good when exposure is discontinued

and metal levels in the body are not high

28
REFERENCES
•Ahmad Bhat, S., Hassan, T., & Majid, S. (2019). Heavy metal toxicity and their harmful effects on living organisms - A review. International Jourrnal of Medical Science and Diagnosis Research (IJMSDR), 3(1).
•Balali-Mood, M., Naseri, K., Tahergorabi, Z., Khazdair, M. R., & Sadeghi, M. (2021). Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic. In Frontiers in Pharmacology (Vol. 12). https://doi.org/10.3389/fphar.2021.643972
•Bruch, J. M., & Treister, N. (2017). Clinical Oral Medicine and Pathology. In Clinical Oral Medicine and Pathology. https://doi.org/10.1007/978-3-319-29767-5
•DeLong, L., & Burkhart, N. W. (2013). General and oral pathology for the dental hygienist. In General and Oral Pathology for the Dental Hygienist.
•Ghom, A. G., & Ghom (Lodam), S. A. (2017). Textbook of Oral Medicine. Stomatology Edu Journal, 4(2). https://doi.org/10.25241/stomaeduj.2017.4(2).bookreview.4
•Glick, M., Greenberg, S. M., Lochart, B. P., & Challacombe, J. S. (2021). Burket’s Oral Medicine : Thirteenth Edition. In John Wiley & Sons, Inc.
•Humairo, M. V., Soedjajadi, D., Program, K., Sarjana, S., & Masyarakat, K. (2017). KADAR TIMBAL DARAH DAN KELUHAN SISTEM SYARAF PUSAT PADA PEKERJA PERCETAKAN UNIPRESS SURABAYA Blood Lead Levels and Healthy Complaint in Printing Workers of
Unipress Surabaya.
•Johnson-Arbor, K., Tefera, E., & Farrell, J. (2021). Characteristics and treatment of elemental mercury intoxication: A case series. Health Science Reports, 4(2). https://doi.org/10.1002/hsr2.293
•Langlais, R. P., Miller, C. S., & Gehrig, J. S. (2017). Color Atlas of Common Oral Disease, Fifth Edition. In Wolters Kluwer.
•Laskaris, G. (2019). Pocket Atlas of Oral Diseases, 3. ed. In Pocket Atlas of Oral Diseases, 3. ed. https://doi.org/10.1055/b-006-161180
•Marginean, C. O., Melit, L. E., Moldovan, H., Lupu, V. V., & Marginean, M. O. (2016). Lead poisoning in a 16-year-old girl: A case report and a review of the literature (CARE compliant). Medicine (United States), 95(38).
https://doi.org/10.1097/MD.0000000000004916
•Mukherjee, D. (2020). Pigmented lesions of the oral cavity – A brief review. Journal of Dental Research and Review, 7(4). https://doi.org/10.4103/jdrr.jdrr_38_20
•Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2019). Developmental Defects of the Oral and Maxillofacial Region. In Color Atlas of Oral and Maxillofacial Diseases. https://doi.org/10.1016/b978-0-323-55225-7.00001-4
•Nordberg, G. F., & Costa, M. (2021). Handbook on the Toxicology of Metals: Fifth Edition. In Handbook on the Toxicology of Metals: Fifth Edition (Vol. 1).
•Odell, E. (2017). Cawson’s Essentials of Oral Pathology and Oral Medicine. In Elsevier.
•Pasiga, B. D., Samad, R., Pratiwi, R., & Akbar, F. H. (2019a). Identification of lead exposure through saliva and the occurrence of gingival pigmentation at fuel station Indonesian officers. Pesquisa Brasileira Em Odontopediatria e Clinica Integrada, 19(1).
https://doi.org/10.4034/PBOCI.2019.191.48
•Pasiga, B. D., Samad, R., Pratiwi, R., & Akbar, F. H. (2019b). Identification of lead exposure through saliva and the occurrence of gingival pigmentation at fuel station Indonesian officers. Pesquisa Brasileira Em Odontopediatria e Clinica Integrada, 19(1).
https://doi.org/10.4034/PBOCI.2019.191.48
•Regezi DDS MS, J. A., Sciubba DMD, J. J., & Jordan DDS FRCD FRCPath, R. C. (2017). Oral Pathology. https://doi.org/10.1016/C2013-0-06961-7
•Regezi, J., Sciubba, J., & Jordan, R. (2016). Oral Pathology: Cinical Pathologic Correlations. In Oral Pathology: Cinical Pathologic Correlations.
•Saeed, S., Hasan, S., Kuldeep, & Choudhury, P. (2017). Lead poisoning: A persistent health hazard-general and oral aspects. Biomedical and Pharmacology Journal, 10(1). https://doi.org/10.13005/bpj/1127
•Syed, E. H., Melkonian, S., Poudel, K. C., Yasuoka, J., Otsuka, K., Ahmed, A., Islam, T., Parvez, F., Slavkovich, V., Graziano, J. H., Ahsan, H., & Jimba, M. (2013). Arsenic exposure and oral cavity lesions in Bangladesh. Journal of Occupational and Environmental
Medicine, 55(1). https://doi.org/10.1097/JOM.0b013e31826bb686
•Talarska, P., Boruczkowski, M., & Żurawski, J. (2021). Current knowledge of silver and gold nanoparticles in laboratory research—application, toxicity, cellular uptake. In Nanomaterials (Vol. 11, Issue 9). https://doi.org/10.3390/nano11092454
•Tsai, M.-T., Huang, S.-Y., & Cheng, S.-Y. (2017). Lead Poisoning Can Be Easily Misdiagnosed as Acute Porphyria and Nonspecific Abdominal Pain. Case Reports in Emergency Medicine, 2017. https://doi.org/10.1155/2017/9050713
•Wychowanski, P., & Malkiewicz, K. (2017). Evaluation of Metal Ion Concentration in Hard Tissues of Teeth in Residents of Central Poland. BioMed Research International, 2017, 1–7. https://doi.org/10.1155/2017/6419709
•Yang, N., & Sun, H. (2011). Bismuth: Environmental Pollution and Health Effects. In Encyclopedia of Environmental Health. https://doi.org/10.1016/B978-0-444-52272-6.00374-3
•Yang, Y., Li, S., Wang, H., Liu, M., Tuo, B., Wu, H., Deng, S., & Liu, X. (2020). Chronic lead poisoning induced abdominal pain and anemia: a case report and review of the literature. BMC Gastroenterology, 20(1). https://doi.org/10.1186/s12876-020-01482-x
•Ye, B. J., Kim, B. G., Jeon, M. J., Kim, S. Y., Kim, H. C., Jang, T. W., Chae, H. J., Choi, W. J., Ha, M. N., & Hong, Y. S. (2016). Evaluation of mercury exposure level, clinical diagnosis and treatment for mercury intoxication. In Annals of Occupational and Environmental
Medicine (Vol. 28, Issue 1). https://doi.org/10.1186/s40557-015-0086-8

29
THANKYOU

30