Smokers Melanosis

Intan Nursini Hapsari 2016.07.2.0038

Smoker’s melanosis Para peneliti telah menemukan bahwa adanya peranan pigmentasi melanin diakumulasi oleh macam-macam obat seperti nikotin (bahan campuran polyacylic) yang terkandung dalam sebatang rokok. Ketika nikotin berperan dalam afinitas melanin di rambut, juga berperan dalam afinitas melanin yang terdapat pada kulit dan jaringan lainnya (seperti mukosa mulut). Nikotin yang terdapat dalam sebatang rokok akan menstimulasi secara langsung melanocytes untuk meproduksi melanosomes, dimana akan menghasilkan peningkatan endapan pigmen melanin pada basil melanosis dengan berbagai macam jumlah takaran melanin. Melanosis rongga mulut terjadi pengendapan melanin dalam lapisan sel basal pasa lapisan epitelium mukosa mulut. Pigmentasi melanin pada membran mukosa mulut secara normal dilihat mengelilingi daerah mukosa. Melanosis rongga mulut adalah suatu lesi yang bersifat reversibel, dapat hilang apabila menghentikan kebiasaan merokok. Smoker melanosis yang terjadi pada golongan etnis kulit hitam maupun kulit putih, dimana meningkatnya pigmentasi yang berhubungan langsung dengan kebiasaan merokok (banyaknya jumlah rokok yang dihisap setiap hari, jenis rokok yang dihisap, lama merokok dan cara seseorang menghisap rokok). Pigmentasi gingiva meningkat sebanding dengan konsumsi tembakau. Adanya hipotesis yang didapatkan bahwa kemungkinan nikotin menstimulasi aktivitas melanosit dan produksi melanin atau berhubungan dengan ikatan melanin yang berbahaya pada rokok tembakau. Gambaran klinis yang terlihat pada smokerr’s melanosis adalah menunjukkan bercak coklat difus yang ukurannya beberapa sentimeter dan biasanya terdapat pada gingiva anterior mandibula dan mukosa pipi. Pada perokok pipa menunjukkan pigmentasi pada mukosa bukal. Pada beberapa orang menggunakan rokok seperti rokok putih yang ditempatkan pada kavitas mulut, akan menunjukkan pigmentasi pada palatum keras. Lesi ini tidak mempunyai symptom, perubahan yang terjadi tidak menunjukkan premalignat.

Gigi pada smoker’s melanosis menunjukkan berwarna coklat muda sampai coklat tua dan disertai dengan halitosis menyertai keadaan tersebut disebabkan oleh adanya perubahan aliran darah dan pengurangan pengeluaran ludah mengakibatnya rongga mulut menjadi kering dan lebih anaerob. Smoker’s melanosis biasanya terjadi pada Ras Kaukasian yang menunjukkan prevalensi 31% pada gingiva cekat. Diagnosa banding dari Smoker’s melanosis adalah

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Addison Disease Albright Syndrome Hemochromatosis Neurofibromatosis Oral Malignant Melanoma Oral Nevi

Perawatan yang dilakukan adalah menyuruh pasien untuk berhenti merokok karena alasan kesehatan. Berhenti merokok biasanya menunjukkan hilangnya melanosis selama beberapa periode sampai beberapa tahun. Program berhenti merokok dengan konsultasi dan dibantu oleh lingkungan keluarga akan memberikan keuntungan.

Intan Nursini Hapsari 2016.07.2.0038

Smoker's Melanosis Author Leticia Ferreira, DDS, MS Assistant Professor of Pathology and Medicine, Department of Dental Practice, University of the Pacific, Arthur A Dugoni School of Dentistry http://emedicine.medscape.com/article/1077501-overview

Background The main etiologic factor responsible for melanocytic pigmentation of the oral mucosa in the white population is cigarette smoking. In his 1977 report, Hedin [1]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. Epidemiology 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] The anterior facial gingivae was the most common site for smoker’s melanosis in that study. 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] Studies of soft-tissue lesions in the Middle East and India report a high prevalence and suggested more healthcare attention and community awareness programs are needed.[5, 6, 7, 8, 9]

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.[10] 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.[11]

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 commissural and buccal mucosae. 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.[12] See the images below.

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 nicotinecontaining gum do not develop this condition. Also see Cutaneous Manifestations of Smoking and Smokeless Tobacco Lesions.

Differential Diagnoses 

Albright Syndrome

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Dermatologic Aspects of Addison Disease

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Dermatologic Manifestations of Hemochromatosis

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Dermatologic Manifestations of Neurofibromatosis Type 1

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Oral Malignant Melanoma

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Oral Nevi

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 in an unusual location, 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. See the image below.

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

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.[13, 14] 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, Final Recommendation Statement: Tobacco Use in Adults and Pregnant Women: Counseling and Interventions.[15] 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 eMedicineHealth's Lung Disease and Respiratory Health Center. Also, see eMedicineHealth's patient education article Cigarette Smoking.