Intraoral graphite tattoo

Graphite pencils, in addition to their usual role as teaching tools, may cause traumatic injury and foreign body reaction, especially during early childhood.

A 5 year old healthy female patient was referred from the paediatric clinic because of her father's concern about a blue lesion on the upper gum which has been increasing in size over four months. Intraoral examination showed an asymptomatic, firm, well defined, scalloped, blue–black macule measuring 15 mm×5 mm involving the attached gingiva and extending apically to the mucogingival junction in the area labial to the maxillary left primary central and lateral incisors (fig 1). There was no associated inflammation and the lesion failed to respond to the blanching test. A periapical radiograph of the anterior maxillary region did not show any pathological changes. Differential diagnoses of foreign body pigmentation, melanocytic nevi, and malignant melanoma were considered. A full mucoperiosteal flap was raised, revealing abundance of granulation tissue, destruction of labial cortical bone to the central incisor, and residues of solid black granules (fig 2). Histopathology showed mild chronic inflammatory cell infiltrate with multinucleated giant cells. There was no evidence of cellular atypia and solid granules were consistent with pencil graphite.

Figure 1 Intraoral view showing the macule labial to maxillary left primary central and lateral incisors.

Figure 2 Destruction of alveolar labial bone and presence of black granules.

The most common causes of exogenous localised oral pigmentation are amalgam tattoo, followed by graphite.¹,² Intraoral graphite implantation is common in the anterior palates of younger children; biopsy is mandatory to rule out malignancy.²