Gingival pigmentation is a frequent clinical finding and may be physiologic, systemic, drug-related, neoplastic, or exogenous in origin. The practical challenge for dentists is that some benign pigmented lesions can resemble potentially serious disease, leading to unnecessary referral or biopsy when the clinical context is overlooked [1].   Traditional gingival tattooing is a culturally rooted practice reported mainly in parts of Africa and the Middle East. It may be performed for esthetic reasons, social identity, femininity, or perceived health benefits. Pigment is manually introduced into the attached gingiva using simple instruments and may produce slate-grey, blue-grey, or black discoloration that persists for years [2-4].   The principal diagnostic look-alikes include physiologic/racial pigmentation, melanotic macule, melanocytic nevus, amalgam tattoo, drug-related pigmentation, smoker’s melanosis, and oral melanoma. Distinguishing features include a history of tattooing, stable color over time, bilateral symmetrical distribution, sparing of the marginal gingiva, and the absence of ulceration, bleeding, induration, or rapid change [1,5-13].   This report aimed to document three clinically similar cases of cultural gingival tattooing in West African women, summarize the relevant literature, and provide a practical diagnostic approach that helps clinicians avoid unnecessary invasive procedures while maintaining vigilance for red-flag lesions (Table 1-2).   Objectives   To describe the shared clinical features of three cases of cultural gingival tattooing To summarize the main differential diagnoses and the role of history-taking, examination, and radiography To provide a practical approach for deciding when observation is appropriate and when biopsy/referral is required   Table 1: Summary of the Three Clinical Cases Case Age Country Site/distribution Color/pattern Symptoms/findings Clinical impression A 19 Mauritania Bilateral maxillary attached gingiva, midline to premolars Bluish-grey band No pain, ulceration, induration, or radiographic abnormality Typical cultural gingival tattoo B 56 Senegal Bilateral maxillary attached gingiva, midline to premolars Dense slate-grey, high saturation Asymptomatic; no inflammatory or radiographic changes Typical cultural gingival tattoo C Adult Mauritania/Senegal Bilateral maxillary attached gingiva, midline to premolars Patchy grey-black with lighter zones Asymptomatic; clinically stable; no bony/radiopaque pathology Typical cultural gingival tattoo   Table 2: Practical Differential Diagnosis of Maxillary Gingival Pigmentation Entity Typical clues Radiographic/clinical aids When biopsy/referral is needed Cultural gingival tattoo Bilateral, symmetrical, flat, stable; history of traditional tattooing Clinical exam + history; radiographs usually negative for radiopaque material Usually not needed if typical and stable Amalgam tattoo Adjacent dental restorations; grey-blue focal macule May show radiopaque particles on radiograph If history/radiograph are inconclusive Physiologic/racial pigmentation Diffuse melanin pigmentation; long-standing; ethnic pattern Clinical pattern and history Only if atypical change occurs Oral melanoma / suspicious melanocytic lesion Asymmetry, irregular borders, color variegation, growth, ulceration, bleeding, induration Urgent specialist assessment Biopsy/referral indicated

Three Black female patients from Mauritania and Senegal presented for unrelated dental complaints. In each case, an incidental bilateral pigmentation of the maxillary attached gingiva was identified from the midline to approximately the second premolar region. The pigmentation spared the marginal gingiva and interdental papillae. None of the patients reported pain, burning, swelling, bleeding, ulceration, or a change in lesion size. Palpation revealed no tenderness or induration. Periapical and panoramic radiographs showed no associated dental, osseous, or radiopaque foreign-body pathology. Detailed history confirmed prior traditional gingival tattooing in the country of origin for cultural/cosmetic reasons. Based on the typical appearance, stable history, and absence of suspicious features, biopsy was not indicated.

Published reports describe cultural gingival tattooing as a flat exogenous pigmentation that most often affects the maxillary attached gingiva and is usually bilateral and symmetrical. The color ranges from blue-grey to black depending on pigment material, density, and the time elapsed since tattooing. Prior reports also indicate that the practice is commonly undertaken during adolescence or before marriage in some communities [2-4,12].   The central clinical issue is differentiation from other pigmented lesions. Amalgam tattoo is among the closest mimics, but it is often associated with adjacent restorative history and may show radiopaque particles. Melanotic macules and physiologic pigmentation usually do not have the same sharply patterned cultural history. Oral melanoma, although rare, remains the most important exclusion because delayed diagnosis carries major consequences [5-9,13].   In the present series, the lesions were benign in appearance because they were bilateral, symmetrical, non-elevated, stable, and unaccompanied by bleeding, ulceration, induration, or rapid change. Radiographs helped exclude metallic foreign material or other pathology. These findings, together with the documented history of traditional tattooing, supported a clinical diagnosis without biopsy [2-4,12].   Biopsy should still be considered when any red flags are present, including an unclear history, unilateral/asymmetric distribution, irregular or enlarging borders, variegated pigmentation, nodularity, ulceration, bleeding, pain, induration, or rapid change over time. In routine practice, dentists should document the history, photograph the lesion, note the distribution, and review the patient if uncertainty remains [6,13-15].   Cultural awareness is essential in increasingly diverse clinical settings. Correct recognition of gingival tattooing can reduce patient anxiety and avoid unnecessary invasive procedures, while a structured diagnostic approach preserves safety [12].

Cultural gingival tattooing is a benign form of exogenous oral pigmentation that may mimic disease in multicultural dental practice.   General dentists should obtain a focused cultural and procedural history, assess symmetry and stability, document the lesion photographically, and use radiographs selectively to exclude other causes.   When the history is unclear or red-flag features are present, biopsy or specialist referral is warranted; otherwise, correct diagnosis can prevent unnecessary intervention and patient anxiety.   Authors’ Contributions All authors contributed to study conception, data collection, analysis, manuscript drafting, and final approval.   Informed Consent Written informed consent was obtained for clinical photography and publication of anonymized case details. Funding No specific grant was received for this work.   Conflict of Interest The authors declare no conflict of interest.   Reporting Guideline The case descriptions were organized in accordance with CARE principles to improve reporting consistency.