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identifiable etiologic factor, the term oral melanotic macule Weather et al and Page et al , recently introduced the terms
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has been suggested . labial melanotic macule for lesions on the vermilion border
In the literature, the oral melanotic macule has been given and oral melanotic macule for lesions within the oral cavity.
various inappropriate and erroneous names, such as The term melanotic macule should be reserved for lesions in
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ephelis and lentigo . Ephelis (freckle) is a circumscribed which there is a clinicopathologic correlation between the
brown macule over skin that has been exposed to sunlight. clinical feature of a discrete pigmented macule and the
Histologically, ephelis shows increased melanin histologic feature of hyperpigmentation of the basal-cell layer
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pigmentation in the basal-cell layer without an increase in the and / or the lamina propria .
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number of melanocytes . The term focal melanosis should be used as a histologic
Ephelides are not found on mucous membranes. Although designation when hyperpigmentation of the basal-cell layer
the histologic appearance of the melanotic macule of the oral and/or the lamina propria is associated with clinically
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mucosa is similar to that of ephelis of the skin, it is not at all nonpigmented pathologic conditions .
related to exposure to sun and thus the term ephelis for the Regarding histopathology, the dark colour of the lesion is
intraoral lesion is a misnomer. due to increase in melanin pigment of the basal cell layer, not
The term lentigo has also been suggested for oral melanotic from an increased number of melanocytes. Melanin may also
macules. But since melanotic macules of the oral mucosa do be found in the lamina propria. Further histologic criteria are
not exhibit a significant increase in the number of absence of elongated rete ridges and lack of prominent
melanocytes, the term lentigo is not considered appropriate melanocytic activity. If there is an elogation of rete ridges, a
for this type of lesion. heavily pigmented basal cell layer, and an increase in the
Fig: 2 Post- operative Intra oral photograph after the Fig: 3 Histo-pathologic features suggestive of Oral
excision of Oral Melanotic Macule. Melanotic Macule.
number of normal-appearing basal layer melanocytes, a Melanotic lesions having a duration of fewer than 5 years,
junctional nevus has to be considered. If the melanocytes which have exhibited changes in size or colour or which
show proliferation, atypia, and some irregularity in their exhibit tumefaction, ulceration, or bleeding, should be
arrangement, the histopathologic diagnosis is atypical excised. Lesions with reliable history of more than 5 years
melanocytic hyperplasia, which may correspond clinically to without change in character in which a known cause seems
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early malignant melanoma (melanoma in situ) . evident (trauma, etc.), may be followed or excised, although
In our case, we found melanin in both the basal cell layer and we prefer the latter.
the lamina propira. This agrees with the study conducted by
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Buchner and Hansen . Page et al found that 30% of their REFERENCES
cases had melanin only in the basal cell layer and 3.8% only
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in the lamina propria . 1. Weathers D. R., Corio. R. L, Crawford B. E., Giansant J. S.
The small size, slow growth rate, and flat clinical appearance and Page. L. R. : The labial melanotic macule. Oral Surg Oral
favour a benign diagnosis. Med Oral Pathol 1976 ; 42 : 196 - 205
Oral melanotic macule has to be differentiated from certain 2. Page L. R., Corio R. L., Crawford B. E., Giansant J. S. and
Weathers D. R. : The oral melanotic macule. Oral Surg Oral
other similar conditions exhibiting hyperpigmentation. Racial
Med Oral Pathol 1977 ; 44: 219 - 226
pigmentation is generally diffuse, is genetically acquired and
3. Buchner A. and Hansen L. S. : Melanotic Macule of the oral
seen at birth. It is more common in Caucasians and has been
mucosa. Oral Surg Oral Med Oral Pathol 1979 ; 48 : 244 - 249.
termed as oral melanosis.
4. George E. K., Andrew P. H., William T. R., Louis M. A. and John
The two most important causes of post inflammatory hyper A. S. : Oral Melanotic Macule - A Review of 353 cases. Oral
pigmentation are lichen planus and lupus erythematosis. Surg Oral Med Oral Pathol 1993 ; 76 : 59 - 62
There are certain endocrinal hyper pigmentations. Addison's 5. Trodohl J. N. and Spragul W. G. : Benign and Malignant
disease causes a darkening of the oral mucosa which is Mucosa, an Analysis of 135 cases. Cancer 1970 ; 25 : 812 -
irregular, patchy and found on the gums. 823
Metal deposition can cause discolouration either from copper 6. Bhaskar S. N.: Oral Lesions in the Aged population - a survey
as in Wilson's disease or from amalgam as in an amalgam of 785 cases. Geriatrics 1968 ; 23 : 137 - 149
tattoo. 7. Beeker S. W. Jr. : Pigmentary Lesions oral melanotic macule
It could be associated with syndromes as in Peutz Jeghers on to the skin and oral cavity. Oral surg 1969 ; 28 : 526 -533.
syndrome where freckles are seen not only in the oral cavity, 8. Shapiro. L. and Zegarelli D. J. : The solitary Labial Lentigo - a
clinicopathologic study of 20 cases. Oral surg 1971 ; 31 : 87 -
but also at the distal extremities, Leopard syndrome where
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pigmentation is seen all over the body.
9. Bork. K., Hoede. N., Korting. G. W., Burgdorf. W. H. C. and
Antimalarial drugs like chloroquine can also cause muscosal
Young S. K. : Diseases of the oral Mucosa and the Lips. 2nd
hyperpigmentation which also occurs on other body parts like
Edition, W. B. Saunders Company, 1996 ; 310 - 312
the shinns. 10.Chaudhary A. P., Hampel A. and Gorlin R. L. : Primary
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The treatment of oral melanotic macule is debatable . Malignant Melanoma of the Oral Cavity-a Review of 105
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Although the lesion is completely benign and shows no cases. Cancer 1958 ; 11 : 923 - 928
tendency to recur or to become malignant, sometimes it is 11.Bengel W ., Veltman G., Loevy H. T. and Pierangelo T. :
difficult if to distinguish it cliniclly from other pigmented Differential Diagnosis of Diseases of the Oral Mucosa.
lesions, such as nevus, malignant melanoma in situ, and Quintessence Publishing Co., Inc., Chicago / Illinosi / 1989 :
incipient malignant melanoma. Thus, complete excision of 153 - 201
oral melanotic macule is indicated and histologic
examination or at least be checked at frequent intervals for Reprint Requests to :
Dr. Sham Bhat
any change in size, shape, or colour. This is especially
Head of the Department of paediatric Dentistry,
necessary for lesions of the palate - a location for which
Yenepoya Dental College,
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oral malignant . melanoma has a strong predilection . Kodialbail, Mangalore,
Karnataka,
INDIA.