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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 101-104

Pigmented oral lesion


1 Department of Maxillofacial Surgery and Diagnostic Sciences, King Saud bin Abdulaziz University of Health Sciences, College of Dentistry, Riyadh, Saudi Arabia
2 Department of Oral Pathology and Microbiology, SJM Dental College and Hospital, Chitradurga, Karnataka, India
3 Department of Oral Pathology, Institute of Dental Sciences, Bareilly, Uttarpradesh, India
4 Department of Oral Pathology and Microbiology, DJ College of Dental Sciences and Research, Modinagar, Uttarpradesh, India

Date of Web Publication8-Jan-2018

Correspondence Address:
Dr. Gajendra Veeraraghavan
Department of Maxillofacial Surgery and Diagnostic Sciences, King Saud bin Abdulaziz University of Health Sciences, College of Dentistry, Al Hars Al watani, Ar Rimayah, Riyadh 14611
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_40_17

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  Abstract 


In general dental practice, a dentist may come across various pigmented lesions in oral cavity. In most cases, the lesions are asymptomatic and benign in nature. However, rarely, a pigmented lesion can be a sign of malignancy. We report a case of a pigmented lesion in mandibular gingiva to highlight the importance of biopsy for early diagnosis and prolonged survival of patients.

Keywords: Malignant melanoma, melanocytes, oral malignant melanoma


How to cite this article:
Veeraraghavan G, S Hiremath SK, Sapra G, Singh S. Pigmented oral lesion. Int J Oral Health Sci 2017;7:101-4

How to cite this URL:
Veeraraghavan G, S Hiremath SK, Sapra G, Singh S. Pigmented oral lesion. Int J Oral Health Sci [serial online] 2017 [cited 2019 Sep 20];7:101-4. Available from: http://www.ijohsjournal.org/text.asp?2017/7/2/101/222399




  Introduction Top


Pigmented lesions are commonly found in mouth. The various pigmented lesions include amalgam tattoo, melanotic macule, smoker's melanosis, racial pigmentation, nevus, drug-induced pigmentation, systemic diseases, and malignant lesions such as malignant melanoma. Although most pigmented lesions are benign and of no clinical consequence, clinicians must differentiate between the large number of benign lesions and the rare serious diseases, most notably melanoma. We report a case of pigmented oral lesion in a 59 year old male patient and the literature of the case is reviewed briefly.[1]


  Case Report Top


The patient presented with a painless pigmented swelling in the lower front teeth region of the jaw for 1 month [Figure 1]. The swelling was initially small in size and gradually increased to present size. Swelling was associated with mild pain. There is no history of numbness or loss of sensation in lower jaw. A medical, dental, and family history was noncontributory and there were no adverse habits. The submental lymph nodes were firm and nontender. On palpation, a single, pigmented, nodular exophytic growth presents over the lower anterior alveolar region. The swelling extended from 35 to 45 involving both buccal and lingual vestibule. The color of the overlying mucosa of the mass was showed grayish black pigmentation.
Figure 1: Intraoral picture

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Routine blood investigation was found to be normal. Radiographically, generalized bone loss was noted with missing 41, 42 [Figure 2]. Incisional biopsy was carried out. Histopathologically, under scanner view section showed single piece of tissue. This tissue consists of epithelium overlying connective tissue. Stroma showed predominant tumor islands with melanin pigmentation [Figure 3].
Figure 2: Orthopantomograph

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Figure 3: Photomicrograph showing tumor islands with melanin pigmentation [Magnification 10X]

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Under higher magnification connective tissue showed predominant tumor islands. These islands were chiefly consisting of epithelioid melanocytes. These melanocytes were atypical and invading in the form of sheets, clusters, cords, and strands [Figure 4]. Predominant malignant melanophages and pigmentation were evident. Areas showing endothelial lined blood vessels were evident with extravasated red blood cells. Based on the histopathological features, diagnosis of malignant melanoma was done.
Figure 4: Photomicrographs showing malignant melanophages and pigmentation [Magnification 40X]

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To rule out metastasis radiographs of chest and long bones, computed tomography, magnetic resonance imaging, and sonography of neck and abdomen were done, which were normal. However, fine-needle aspiration cytology of submental lymph node was suggestive of metastatic infiltration of malignant melanoma. Later, the patient was taken up for surgery. Following surgery, the patient was kept under observation with regular follow-up.


  Discussion Top


Oral malignant melanoma (OMM) is an infrequent neoplasia of very aggressive characteristics originated from the malignant transformation of melanocytes of the mucosa. It represents 0.2%–8% of the total cases of melanoma from the other regions of the body [2],[3],[4],[5],[6],[7] and 0.5% of all oral neoplasia.[8],[9] It occurs between 30 and 90 years of age with higher incidence in the 6th decade.[8],[10],[11] In general, it does not have gender predilection,[4],[5] although some authors refer that incidence is slightly higher in males [2],[8] and other in females.[12]

Melanoma is a malignant neoplasm of melanocytes which are derived from the neural crest cells that constitute the melanin pigment of the basal layer of the epithelium. Although most melanomas arise from the skin, they may also arise from mucosal surface or at other site wherein neural crest cells migrate.[13]

It arises approximately four times most frequently in the oral mucosa of the upper jaw, usually on the palate and anterior gingiva.[14] Some cases of involvement of lip, mandibular gingival, and buccal mucosa are reported.[15]

OMM affects all races. In Japan, India and Africa have been reported as having higher incidence than in Western countries.[16]

The etiology of OMM remains unknown in contrast to cutaneous melanoma which is linked to sun exposure. Nevi are considered as potential source of some oral melanomas, but sequence of events is poorly understood. Currently, most melanomas are thought to arise de novo. Many genes are implicated in the development of melanoma, including CDKN2A (P16), CDK (Chromosome 12q15), RB1, CDKN2A9 (P19), and PTEN/MMAC1.[17]

Most of the melanomas are asymptomatic; swelling with pigmentation is usually initial sign of OMM. It may be uniformly brown or black or show variation in color with black, brown, gray, purple, and red shades or depigmentation.[18] Focal pigmentation preceding development of actual neoplasm frequently occurs several months to years before clinical symptoms appear. Pain, ulceration, and bleeding are rare until late in disease.[17] In our case, we found that swelling in labial vestibule showed bluish black pigmentation which makes the clinical provisional diagnosis OMM.

The so-called ABCDE checklist (asymmetry, border irregularities, color variations, diameter >6 mm, and elevation or a raised surface), which is used in the identification process of cutaneous melanoma, could also be of some help in the diagnosis of oral melanoma. More than 95% of lesions are anti-S100 antigen positive, and more specific markers include HMB45, Melan-A, and antityrosinase. Special stains such as Mason Fontana and melanin bleach are also helpful in the diagnosis of malignant melanoma.[13]

Radiographically, primary and secondary melanomas very rarely involve the jaw bones. However, when they do involve the bone, they are indistinguishable from osteomyelitis while others have appearance which is to be found with any other lytic malignant tumor. In our case, we found that there was irregular interdental bone loss with mandibular anterior teeth region. Radiographically, such type of internal bone loss can be seen in early benign condition (reactive lesion), early malignant lesion as well as in pulp and periodontal diseases. It will be difficult to diagnose OMM radiographically when the lesion is an early period or small in size.[19]

The differential diagnosis include amalgam tattoo, melanotic macule, smoker's melanosis, racial pigmentation, nevus, drug-induced pigmentation, and systemic diseases.[1] The nature of oral pigmentation can sometimes only be established after further investigation. In patients with localized hyperpigmentation, in order to exclude melanoma, radiographs may be helpful and biopsy may be indicated, particularly where there is a solitary raised lesion, a rapid increase in size, change in color, ulceration, pain, evidence of pigmented spots, or regional lymph node enlargement. If early detection of oral melanoma is to be achieved, all the pigmented oral cavity lesions should be viewed with suspicion. A lesion with clinical features as above which is seriously suggestive of malignant melanoma are best biopsied at the time of definitive operation. In patients with general or multiple hyperpigmentation, specialist referral is indicated.[20]

OMM has a predilection for metastasis to lung, liver, brain, and bones. Documented cases of metastasis to oral cavity are rare but include secondary lesions of gingival, palate, tongue, and tonsils. Approximately 13%–19% of patients have lymph node metastasis, and another 16%–20% are likely to develop metastases subsequently.[6]

The recommended treatment for oral melanoma is wide surgical excision. However, melanoma is not radiosensitive, but some patients show a good response in early or in situ melanomas. Immunotherapy has been successfully used, but chemotherapy has demonstrated a relatively low response rate. Dacarbazine, interferon-gamma, and tumor necrosis factor alpha-2b have been described as chemotherapeutical and immunotherapeutical treatments associated with Bacillus Calmette–Guerin Vaccine and recombinant interleukin in different combinations.[21] Although our case of OMM was treated by wide surgical excision, there has been no recurrence and regular follow-up is being done.

The prognosis of oral melanoma is far worse than cutaneous melanoma. The reported 5-year survival rate for OMM has ranged from 4.5% to 29% with median survival rate of 18.5 months after initial diagnosis, whereas 5-year survival rate for patients with cutaneous melanoma ranges from 35% to 45%.[21]


  Conclusion Top


The oral cavity is a common site for pigmented lesions, and most of them are benign in nature. Dentists should consider the possibility of malignant melanoma during the differential diagnosis of a pigmented lesion. When suspicious, the dentist should refer to a specialist or perform biopsy and do regular follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflflicts of interest.



 
  References Top

1.
Auluck A, Zhang L, Desai R, Rosin MP. Primary malignant melanoma of maxillary gingiva – A case report and review of the literature. J Can Dent Assoc 2008;74:367-71.  Back to cited text no. 1
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2.
Rapini RP, Golitz LE, Greer RO Jr., Krekorian EA, Poulson T. Primary malignant melanoma of the oral cavity. A review of 177 cases. Cancer 1985;55:1543-51.  Back to cited text no. 2
    
3.
Patton LL, Brahim JS, Baker AR. Metastatic malignant melanoma of the oral cavity. A retrospective study. Oral Surg Oral Med Oral Pathol 1994;78:51-6.  Back to cited text no. 3
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Tanaka N, Amagasa T, Iwaki H, Shioda S, Takeda M, Ohashi K, et al. Oral malignant melanoma in Japan. Oral Surg Oral Med Oral Pathol 1994;78:81-90.  Back to cited text no. 4
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Oriba HA, Stanley R, Snow SN, Mohs FE. Oral malignant melanoma treated with Mohs micrographic surgery by fixed-tissue technique. Arch Otolaryngol Head Neck Surg 1998;124:199-201.  Back to cited text no. 5
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Strauss JE, Strauss SI. Oral malignant melanoma: A case report and review of literature. J Oral Maxillofac Surg 1994;52:972-6.  Back to cited text no. 6
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Smyth AG, Ward-Booth RP, Avery BS, To EW. Malignant melanoma of the oral cavity – An increasing clinical diagnosis? Br J Oral Maxillofac Surg 1993;31:230-5.  Back to cited text no. 7
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Delgado Azañero WA, Mosqueda Taylor A. A practical method for clinical diagnosis of oral mucosal melanomas. Med Oral 2003;8:348-52.  Back to cited text no. 8
    
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Hicks MJ, Flaitz CM. Oral mucosal melanoma: Epidemiology and pathobiology. Oral Oncol 2000;36:152-69.  Back to cited text no. 9
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Cebrián Carretero JL, Chamorro Pons M, Montesdeoca N. Melanoma of the oral cavity. Review of the literature. Med Oral 2001;6:371-5.  Back to cited text no. 10
    
11.
Gorsky M, Epstein JB. Melanoma arising from the mucosal surfaces of the head and neck. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:715-9.  Back to cited text no. 11
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Lengyel E, Gilde K, Remenár E, Esik O. Malignant mucosal melanoma of the head and neck. Pathol Oncol Res 2003;9:7-12.  Back to cited text no. 12
    
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Femiano F, Lanza A, Buonaiuto C, Gombos F, Di Spirito F, Cirillo N, et al. Oral malignant melanoma: A review of the literature. J Oral Pathol Med 2008;37:383-8.  Back to cited text no. 13
    
14.
Hashemi Pour MS. Malignant melanoma of the oral cavity: A review of literature. Indian J Dent Res 2008;19:47-51.  Back to cited text no. 14
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Hayashi T, Ito J, Katsura K, Honma K, Shingaki S, Ikarashi T, et al. Malignant melanoma of mandibular gingiva; the usefulness of fat-saturated MRI. Dentomaxillofac Radiol 2002;31:151-3.  Back to cited text no. 15
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Moore ES, Martin H. Melanoma of the upper respiratory tract and oral cavity. Cancer 1955;8:1167-76.  Back to cited text no. 16
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Rajendran R, Sivapathasundaram B. Benign and malignant tumours of oral cavity. In: Shafer, Hine, Levy's Shafer's Text Book of Oral Pathology. 6th ed., Vol. 80. India: Elsevier; 2009. p. 218.  Back to cited text no. 17
    
18.
Meleti M, Leemans CR, Mooi WJ, Vescovi P, van der Waal I. Oral malignant melanoma: A review of the literature. Oral Oncol 2007;43:116-21.  Back to cited text no. 18
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Worth HM. Principles and Practice of Oral Radiologic Interpretation. Chicago: Year Book Medical Publisher; 1963. p. 559-60.  Back to cited text no. 19
    
20.
Scully C, Felix DH. Oral medicine – Update for the dental practitioner: Red and pigmented lesions. Br Dent J 2005;199:639-45.  Back to cited text no. 20
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Hashemipour MS. Malignant melanoma of the oral cavity. J Dent 2007;4:44-51.  Back to cited text no. 21
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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