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Indian Journal of

Dental Research

ISSN: 0970 - 9290

Volume: 19 / Issue: 1 / January - March 2008

CONTENTS

Editorial
Authorship
B Sivapathasundharam ........................................................................................................................................................................

Original Research
Effect of chemical surface treatments and repair material on transverse strength of repaired acrylic denture resin
Mahroo Vojdani, Sakineh Rezaei, Lila Zareeian ...................................................................................................................................

Intrusion in implant-tooth-supported fixed prosthesis: An in vitro photoelastic stress analysis

Murali Srinivasan, Padmanabhan TV ....................................................................................................................................................

Self-assessment of facial form oral function and psychosocial function before and after orthognathic surgery:
A retrospective study
Vinod Narayanan, Shankar Guhan, Sreekumar K, Ashok Ramadorai ..................................................................................................

12

The effect of post-core and ferrule on the fracture resistance of endodontically treated maxillary central incisors
Sendhilnathan Dakshinamurthy, Sanjna Nayar ....................................................................................................................................

17

The effect of ibuprofen on bleeding duringperiodontal surgery

Shiva Prasad BM, Vijaya M, Sridhara B Reddy, Sudhir R Patil, Nagaraj B Kalburgi .............................................................................

22

In vitro evaluation of antibacterial activity of an herbal dentifrice against Streptococcus mutans and
Lactobacillus acidophilus
Yogesh Kumar Vyas, Maheep Bhatnagar, Kanika Sharma ...................................................................................................................

26

Effect of three commercial mouth rinses on cultured human gingival fibroblast: An in vitro study
Flemingson, Emmadi Pamela, Ambalavanan N, Ramakrishnan T, Vijayalakshmi R ............................................................................

29

The diagnostic and prognostic implications of silver-binding nucleolar organizer regions in periodontal lesions
Mini Saluja, Vandana KL ......................................................................................................................................................................

36

Review Articles
Platelet-rich fibrin: Evolution of a second-generation platelet concentrate
Sunitha Raja V, Munirathnam Naidu E .................................................................................................................................................

42

Malignant melanoma of the oral cavity: A review of literature

MS Hashemi Pour ................................................................................................................................................................................

47

Dentistry and Ayurveda - IV: Classification and management of common oral diseases
Sunita Amruthesh ...............................................................................................................................................................................

52

Case Reports
Odontogenic myxoma of maxilla
Sivakumar G, Kavitha B, Saraswathi TR, Sivapathasundharam B ........................................................................................................

62

Ewings sarcoma of the maxilla

Vikas Prasad B, Ahmed Mujib BR, Bastian TS, David Tauro P .............................................................................................................

66

Two-rooted mandibular second premolars: Case report and survey

Prakash R, Nandini S, Suma Ballal, Sowmya N Kumar, Kandaswamy D .............................................................................................

70

Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma

Manjunatha BS, Kumar GS, Vandana Raghunath ................................................................................................................................

74

Central giant cell granuloma of the anterior maxilla

Amar A Sholapurkar, Keerthilatha M Pai, Auswaf Ahsan .....................................................................................................................

78

Symposium Report
ISDR International symposium on research priorities in Dental Science and technology in Asia and Africa
M Rahamatulla .....................................................................................................................................................................................

83

Journal Reviews
Einstein A, Sathyakumar M ..................................................................................................................................................................

85

Book Review ................................................................................................................................................................................

51

Indian J Dent Res, 19(1), 2008

Copyright 2008 by Editor-in-chief, IJDR

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REVIEW ARTICLE
Malignant melanoma of the oral cavity: A review of literature
MS Hashemi Pour

Department of Oral Medicine,

Faculty of Dentistry, Kerman
University of Medical Sciences,
Kerman, Iran

Received
Review completed
Accepted
PubMed ID

: 20-05-07
: 11-06-07
: 12-06-07
:

ABSTRACT
Oral malignant melanoma is a rare aggressive neoplasm of the middle age. This malignancy
commonly affects male subjects and is more frequently seen at the level of the hard palate and
gingiva. At present, the clinicopathological classification of oral melanoma is not yet clearly
outlined; consequently, the skin form is often taken as a reference. In many cases (up to 30%), the
diagnosis of melanoma is made on lesions, which have evolved from the pre-existing pigmented
lesions. The poor prognosis of oral melanomas requires that pigmented lesions of undetermined
origin be routinely biopsied. The surgical approach, combined with the chemotherapeutic one,
is the first choice treatment. The purpose of this study is to review literature that has been
published about malignant melanoma of the oral cavity.
Materials and Methods: Thirty-eight published articles and 8 textbooks related to oral malignant
melanoma and been published in the last two decades are reviewed.
Conclusion: The review of literature in the field of malignant melanoma of the oral cavity
show that this malignancy might be different from cutaneous malignant melanomas, and new
criteria for diagnosis and therapy should be considered for this disease. Physicians and dentists
who treat problems of the oral cavity should be aware of the need for early diagnosis of oral
melanomas and performing biopsies of doubtful pigmented lesions.
Key words: Malignant oral, melanoma

Melanocytes in skin provide a protective function against

the harmful effects of sun exposure. The function of
melanocytes in mucosa is unknown. In oral mucosa,
melanocytes are located along the tips and peripheries
of the rete pegs. Melanocytes in single tissue sections
are found in the gingiva with a ratio of 1 melanocyte to
15 keratinocytes. Melanocytes, nevus cells, and melanoma
cells differ markedly in their cytologic appearance,
organization, and biologic characteristics. Nevus cells lack
cytologic atypia, pleomorphism, and rarely have mitotic
activity. Melanoma cells retain some features of nevus
cells, such as lack of dandritic processes, round to spindled
shape, and loss of contact inhibition. These malignant cells
possess considerable pleomorphism, with large, irregular
hyperchromatic nuclei, prominent nucleoli, and have
readily detectable mitotic activities.[1]
The incidence of melanoma has been steadily increasing in
the past several decades. This increased frequency of newly
diagnosed melanomas has been observed worldwide and is
of the order of 3-8% in a year. This increase in the incidence
of melanoma has been sustained over time. In the United
States in 1935, the lifetime risk of an invasive melanoma
Correspondence:
Dr. Hashemi Pour MS,
E-mail: m_s_hashemipoor@yahoo.com
47

developing was only 1 in 500; in 1960, 1 in 600; in 1992,

1 in 105; in 1996, 1 in 88, and the lifetime risk would be
1 in 75 by the year 2000.[2]
Melanoma could infrequently arise from mucosal surfaces.
The most common sites are the mucosal surfaces of the head
and neck (typically involving the nasal and oral cavity),
vulva, and anorectal mucosa.[2,3] Head and neck mucosal
melanomas are much less common than their cutaneous
counterparts and probably represent less than 1-8% of all
melanomas.[3-11]

EPIDEMIOLOGY
Oral melanoma is rare, and incidence rates of oral melanoma
are not available. They are, however, estimated to
represent 1-2% of all oral malignancies[1,3-18] and accounting
for about 0.2-8% of all melanomas.[19,20] It is frequent in
countries like Japan, Uganda, and India.[3,6,10,11,14,21] Among
the Japanese, oral melanoma accounts for 11-14% of all
cases of melanomas.[4,6,10] In Australia, primary malignant
melanoma of the oral mucosa is rare.[8] In the East, mucosal
malignant melanoma seems to be more common than the
West.[10]
Primary oral melanomas are extremely rare in the United
States and account for less than 2% of all melanomas.
Indian J Dent Res, 19(1), 2008

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Malignant melanoma of the oral cavity

Hashemi Pour

At 1.2 cases per 10 million people per year, the annual

incidence of oral melanoma is very low.[22]
Recent and major investigations in Africa showed
oropharyngeal melanoma as 1.7% of all melanomas in Sudan
and oral melanomas as 0.9% of all melanomas of Nigeria. It
was suggested that mouth is a common site for melanoma
in Uganda, with a frequency of 8% in 125 melanomas. This
proportion was reduced to 4.6% in a similar study with a
slightly larger sample.[14,17]
In a study by Jackson and Simpson, primary malignant
melanoma of the mouth represented less than 2% of all
malignant melanomas.[23]
Robertson et al. and Reddy et al. showed that primary
malignant melanoma of the oral cavity comprises 0.4-1.3%
of all malignant melanomas.[9,10] Van der Wall showed
that only 2.5% of all melanomas were oral primaries.[8]
Subsequent studies confirm the predominance of oral
melanoma in American, Caribbean, African, and Indian
population. Indian studies show between 20.41% and 34.4%
of all melanomas at mucosal surface, and up to 16% of these
tumors are intraoral.[10]
Oral melanoma is excessively uncommon at any site in
prepubertal children of all races.[14,18] This malignancy is
a lesion of the adulthood, rarely occurring under the age
of 20 years. In different studies, the highest incidence of
malignant melanoma is in the fth decades of life (40-70
years).[3-6,8,9,15,16,18,23-26] Barker et al. showed that the average
age of patients with mucosal melanoma was 56 years, and
the age range was 22-83 years.[27]
Males appear to be more
females.[1,3,7-10,12,14-16,23,25,27-29]

often

affected

than

From different studies, the male-to-female ratio ranges

between 1/1 and 2/1.[3,8,9,15,16,30]
Barker et al. showed that the gender distribution was 37 male
to 13 female (ratio = 2.8).[27] As per a study in Netherlands,
oral malignant melanomas appeared to be slightly more
common in men.[8] In their review of literature, Hicks and
Flaitz reported a male predilection and an age range of 22-83
years, with a mean age of 56 years.[1]
In addition, Hashemi Pour reported a male prediction (maleto-female ratio, 2/1) and age range between 56 and 77 years.
The mean age of patients was 69.2 years.[31]
Morris and Horn found that malignant melanomas are
4.4 times more common in Whites than in Negroes. Reports
of cases of oral melanomas in Blacks are infrequent.[14]
Primary melanoma occurs most frequently in the
Indian J Dent Res, 19(1), 2008

hard palate and maxillary gingiva; other oral sites are

mandible, tongue, buccal mucosa, and upper and lower
lip.[1,3-5,7-10,12,15,17,21,23,25,27,29,30,32,33]
The ethnic groups most commonly affected by oral
melanomas are Japanese, Black Africans, Native Americans,
and Hispanics.[34]

ETIOLOGY
In contrast to well-established etiologic factors participating
in the evolution of cutaneous melanoma, such factors are
either not a consideration (sun exposure, tendency to tan)
or have not been studied extensively (familial history,
syndromes, cytogenetic defects) with mucosal melanomas
of the oral cavity. Probably the major reason for this lack of
understanding regarding mucosal melanomas is the rarity
of this malignancy.[1,12,27,35]
No etiologic factors have been identied for oral melanomas.
Risk factors have also remained elusive. There appear to be
no geographic differences and possibly only slight ethnic
and gender differences.[7]
Like their cutaneous counterparts, primary oral melanomas
are believed to arise either from nevus, pre-existing
pigmented areas or de novo (30% cases).[1-3,5,6,8,12,15,18,23,36]
Some oral melanomas are believed to originate from
junctional nevis. Despite such observations, risk factors such
as fair complexion and light hair, a tendency to sunburn,
a history of painful or blistering sunburn in childhood,
an indoor occupation with outdoor recreational habits, a
personal history of melanoma, and a personal history of
dysplastic or congenital nevus (xeroderma pigmentosum
and basal cell nevus syndrome) have no role in the etiology
of oral melanomas. Rarely, oral melanomas arise from preexisting Hutchinsons malignant lentigo, which is believed
to occur occasionally in the oral mucosa.[5,6]
In the mouth, mechanical traumas including injury from
ill-tting prostheses and infection have been cited as
possible causative factors, but there is no proof of their
etiological role.[2,14]
It is conceivable that oral habits and self-medication may
be of etiological signicance in some Indian and African
groups.[2,14] Probably, racial pigmentation bears a negative
relationship to melanoma.[9]

CLINICAL FEATURES
Clinically, the tumors are classied into ve types: 1 pigmented nodular, 2 - nonpigmented nodular, 3 - pigmented
macular, 4 - pigmented mixed, and 5 - nonpigmented mixed
type.[37] Melanoma of the oral cavity may occur with or
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Malignant melanoma of the oral cavity

without a radial growth phase.[2] The clinical coloration

of oral melanomas has a wide range, which can appear as
black, gray, purple, or even reddish. While some lesions
are uniform in color, others exhibit marked variation. The
lesions are asymmetric, irregular in outline, and occasionally
multiple. The surface architecture of oral melanomas ranges
from macular to ulcerated and nodular.[4,5,7,15]
Some of these tumors are amelanotic. Amelanotic oral
malignant melanoma (AOMM) is a rare tumor, which is
difcult to diagnose.[38] In two different studies, less than
10% of oral melanomas were described as amelanotic.[1,27]
Another unusual feature is the pseudocarcinomatous
hyperplasia. This feature has been reported previously in
association with melanotic lesions, such as Spitz nevi.[39]
Few symptoms are found early in the malignancy. The
patients attention may be drawn to the lesion by the
presence of a swelling or mass, especially in a pigmented area,
possible interference with the t of dentures, hemorrhage,
and loosening of teeth. Pain is an uncommon symptom
of malignant melanoma, generally found in the advanced
stages.[3,5,8,23,25,27] The tumor causes extensive destruction of
the underlying bone in 78% of cases.[5]

HISTOLOGICAL FEATURES
Histologically, the presence of atypical melanocytes (usually
larger than normal melanocytes and having varying degrees
of nuclear pleomorphism and hyperchromatism) in the
epithelial and connective tissue junction, high density of
melanocytes, and atypical cells in the biopsy of melanotic
lesions of the oral mucosa are suspicious for oral malignant
melanoma.[6,40]
In most instances, the cells of melanoma contain melanin
granules, but they may demonstrate no melanin production
(amelanotic melanoma). Lack of production may cause
diagnostic confusion at light microscopic level because
melanoma can mimic a variety of undifferentiated tumors.
Immunohistochemical studies showing S-100 protein,
MART-1, and HMB-45 reactivity of the lesional cells are
benecial in distinguishing such melanomas from other
malignancies.[6]

DIAGNOSIS
Diagnosis of oral mucosal melanomas may be difcult for
several reasons, including small biopsy size, unrepresentative
sampling, biopsy of late-stage lesions, lack of clinical data,
and lack of recognition of early in situ lesions by both
clinician and pathologist.[7] Because of frequent delay in
diagnosis, the tumors are often diagnosed after they grow
deeper than the average cutaneous melanoma.[24]
Tanaka et al. showed that pRb2/p130 may be inversely
49

Hashemi Pour

correlated with the malignancy of oral malignant melanoma,

but further study is needed.[41]
CT and MRI studies should be undertaken to explore
regional metastases to the submandibular and cervical
lymph nodes. Incisional biopsy is the method of choice
for diagnosis.[4] The nding of a melanotic oral lesion in a
patient presents the difculty in deciding whether or not to
do biopsy. The relatively high incidence of malignant versus
benign melanotic lesions suggests that melanotic lesions of
the oral mucosa should be assessed with some care.[3]

DIFFERENTIAL DIAGNOSIS
Differential diagnosis includes oral melanotic macule,
smoking-associated melanosis, medication-induced melanosis
(antimalarial drugs and Minocycline), melanoplakia,
pituitary-based Cushings syndrome, postinflammatory
pigmentation, melanoacanthoma, melanocytic nevi of the
oral mucosa, blue nevi, nevi of Spitz, Addisons disease,
Peutz-Jeghers syndrome, amalgam tattoo, Kaposis sarcoma,
physiologic pigmentation, pigmentation related with the use
of heavy metals, and many other conditions sharing some
macroscopic characteristics.[40,42,43]
Moreover, it is necessary that oral malignant melanoma
should be under differential diagnosis than other malignant
entities, such as poorly differentiated carcinoma and large
cell anaplastic lymphoma.[40]
Amelanotic malignant melanoma without radial growth
phase may be misdiagnosed as epulis or squamous cell
carcinoma.[38]

MANAGEMENT
Surgery is the mainstay of treatment, but it is often difcult
because of anatomic restraints. Although melanoma is
classically not very radiosensitive, patients have occasionally
had good response to radiation therapy, especially in early
melanomas or in melanomas in situ. Other treatment
modalities are similar to those used for cutaneous melanoma.
Immunotherapy has been used, and chemotherapy has a low
response rate.[4-6,8,9,13,17,21,24-26,32,35,36]
Dacarbazine-DTIC and INF-alpha-2b have been described
as chemotherapical and immunotherapical treatments
associated in different combinations of BCG and recombinant
interleukin-2 (rIL-2).[44]

PROGNOSIS AND SURVIVAL

Most oral melanomas are large at presentation and have a poorer
prognosis than cutaneous melanoma.[3,6,7,12,13,16,17,18,25,36,45]
Cutaneous melanomas can be graded by Clark levels or
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Malignant melanoma of the oral cavity

Hashemi Pour

the Breslow tumor thickness grading system. The former

classication assesses the depth of invasion, whereas Breslows
system measures the thickness of the tumor from the surface
of the epidermis to the greatest depth of the tumor. The risk
for developing metastatic lesions from primary cutaneous
melanomas increases with tumor thickness. The Breslow and
Clark grading systems have not been validated as prognostic
predictors in oral melanomas, probably owing to the rarity of
this lesion. Additionally, in contrast to cutaneous melanomas,
most oral melanomas are larger than 4 mm at the time of
initial presentation. This factor, together with inadequate
resection of margins and higher stage at initial diagnosis, may
contribute to the discrepancy in patients 5-year survival rates
between cutaneous melanoma (80%) and oral melanomas
(15%).[1] In general, the survival rates are poor and are worse
for those with metastasis.[23]

9.

Chaudhry et al. reported that the average duration of life

from the point of diagnosis was about 18 months. Sampat and
Sirsates reported that 79% of patients died within 5 years.[5]
In addition, Vairaktaris et al. showed that the 5-year survival
rate of intraoral melanoma does not exceed 5-9%.[46]

17.

Factors that are signicant in predicating worse diseasespecic survival include high clinical stage at presentation,
tumor thickness greater than 5 mm, presence of vascular
invasion, absence of melanosis, and development of nodal
and distant metastases.[5,6,8]

CONCLUSION

10.
11.

12.
13.
14.
15.
16.

18.
19.
20.
21.
22.
23.

The review of literatures in the eld of oral melanoma shows

that oral malignant melanoma might be different from
cutaneous malignant melanoma, and that new criteria for
diagnosis and therapy should be considered for this disease.

24.

Dentists and physicians who treat problems in the oral cavity

should be aware of the need for early diagnosis of melanoma
and performing biopsies of any pigmented lesion.

27.

25.
26.

28.

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How to cite this article: Hashemi Pour MS. Malignant melanoma of the oral
cavity: A review of literatures. Indian J Dent Res 2008;19:47-51.
Source of Support: Nil, Conflict of Interest: None declared.

BOOK REVIEW
Review of oral pathology (with explanatory
answers)
Shamim T
Publisher: Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, 2007,
1st edition, Pages: 258

Multiple choice questions (MCQs) have become an essential part of undergraduate, postgraduate and entrance
examinations. Dr. T. Shamim, in his book Review of Oral Pathology, has presented MCQs in oral pathology in a chapterwise fashion. Further he has provided reasons for the correct answers and has also appreciably given added information
regarding the alternative options. Thus the book summarises all the chapters of a standard oral pathology textbook
thereby helping the students of dentistry to assess their understanding of the subject in an objective manner.
The author has also included eight self-evaluation papers based on questions derived from various chapters to assist
the student in assessing his/her preparation. The book could however be improved by including more questions in
chapters such as odontogenic cysts and tumours and HIV infection.
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Indian J Dent Res, 19(1), 2008