Background: Pigmentations of the oral cavity are commonly noted in clinical practice and may have physiologic, non-physiologic, or pathologic etiologies. The most common non-physiologic localized pigmentation is the amalgam tattoo; another, less common, non-physiologic pigmentation is the graphite tattoo. Graphite tattoos may easily be confused with amalgam tattoos but have only infrequently been reported in the literature.

Methods: This case report discusses a patient with a localized pigmented lesion involving the free gingiva, attached gingiva, and alveolar mucosa. The patient was referred for esthetic enhancement of the area in question. Dental history revealed trauma to the area involving falling on a pencil as a child. The lesion was excised and submitted for histologic examination; a subepithelial connective tissue graft was harvested and utilized to prevent an esthetic defect.

Results: Histologic evaluation confirmed graphite within the soft tissue as the etiology of the discoloration. At the 2-month postoperative appointment, a highly esthetic outcome was obtained utilizing a connective tissue graft.

Conclusions: Although less common than the amalgam tattoo, the graphite tattoo may be encountered in the course of routine dental examinations and should be included in a differential diagnosis of any localized pigmented lesion. Although histologic evaluation is necessary to rule out pathology, if the dental history is consistent with the clinical impression of a nonpathologic lesion, such as the graphite tattoo in this case report, treatment with an autogenous connective tissue graft at the time of excision can produce a highly esthetic result and avoid additional surgical procedures in the future. J Periodontol 2005;76:1572-1575.