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A 60-year-old female patient with an unremarkable medical history presented with a
grayish patch on her upper right gums. She also wanted to get her broken tooth fixed.
The patient noticed this patch 1 year prior, and its size had not increased since
then. On intraoral examination, a flat grayish diffuse pigmentation was present on
the right upper buccal alveolar mucosa adjacent to the broken second premolar, measuring
about 1 cm × 2 cm (Figure, A, black arrow). The pigmentation was nontender, with an intact overlying mucosal
surface and no ulceration. The patient was asymptomatic, with absence of lymphadenopathy.
Intraoral periapical radiograph showed a radiopacity at the apical third region of
the root of the second premolar (Figure, B, black arrow). Further questioning revealed that this tooth had undergone root
canal treatment along with periapical surgery and possible retrograde filling with
amalgam around 20 years prior. Amalgam is a common material used for dental fillings
and it contains silver, tin, mercury, and other metals.
Such grayish pigmentation can be caused by the diffusion of dental amalgam into the
soft tissue during dental procedure and is termed ‘amalgam tattoo’. Other exogenous
pigmentations that can mimic an amalgam tattoo include graphite, coal dust, and intentional
tattooing, or it can even be confused with melanotic lesions like pigmented nevi,
oral melanotic macule, oral melanoacanthoma, and melanoma.
No biopsy was performed in this case, as the clinical findings and radiographic evidence
of restoration of silver amalgam was clearly suggestive of an amalgam tattoo. Once
the diagnosis of an amalgam tattoo has been established, the removal of this lesion
is not necessary, except for aesthetic reasons.