oral pathology

Editor:
JAMES J. SCIUBEA, D.M.D., Ph.D.
American Academy of Oral Pathology
Department of Dentistry
Long Island Jewish-Hillside Medical-Center
New Hyde Park, New York 11042

Pigmented nevi of the oral mucosa: A

clinicopathologic study of 36 new cases
and review of 155 cases from the
literature
Part II: Analysis of 191 cases

Amos Buchner, D.M.D., M.S.D.,* and Louis S. Hansen, D.D.S., M.S., M.B.A.,**
San Francisco, Calif.

DIVISION OF ORAL PATHOLOGY-, DEPhRTMENT OF STOMhTOLOGY. SCHOOL OF DENTISTRh-. ClhlVERSITk

OF C\l-IFORNI.2. SAY FRANCISCO

Review and analysis of data on 191 cases of oral pigmented nevi from the literature and from two studies
at the University of California, San Francisco, revealed that nevi of the intramucosal type are the most
common, followed by the common blue nevus. Compound and junctional nevi are rare, and combined nevi
are the rarest. The data on location, presence of clinical pigmentation, configuration, size, and duration of
the nevi, as well as on the patient’s age, sex, and race, are analyzed. Blue nevi were found mostly on the
hard palate, whereas intramucosal nevi occurred on the buccal mucosa, on the gingiva. and on the lips as
well as on the palate. Nonpigmented nevi were especially common (22%) in the intramucosal group. Most
oral nevi are raised, which can be of help in the differential diagnosis. Oral nevi are small, most being
between 0.1 and 0.6 cm at the largest dimension. Because the malignant potential of oral nevi is still
uncertain and because preexisting macular pigmentation is present in about one third of all patients with
oral melanoma, it is advisable to accurately diagnose all oral pigmented lesions, many of which will require
microscopic examination.
(ORAL SURG. 0~41. MED. ORAL PATHOL. 1987;63:676-82)

I n the first part of this study, we reported 36 new

cases of pigmented nevi of the oral cavity from the
files of the Oral Pathology Diagnostic Laboratory at
the University of California, San Francisco (UCSF),
and analyzed their histologic and clinical features.’
The purpose of this second part is to combine all of
the cases reported from UCSF and to compare this
This study was supported in part by a grant from the Donald T.
Elliott Oral Cancer Research Fund.
*Visiting Professor,
**Professor and Chairman.
large series from a single source with other cases
reported in the English-language literature.
MATERIAL AND METHODS
The sources of material for the UCSF series were
the study of 32 casespublished in 1979,?a report of a
case of junctional nevus,’ a report of a case of
combined nevus,J and the recent study of 36 new
cases.’Thus, 70 casesfrom UCSF were available for
evaluation.
The data collected from the literature were based
on the 75 cases reviewed in 19805as well as on an

676
Volume 63 Pigmented nevi of oral mucosa 677
Number 6

additional 43 casesreported since that last review.6-16 Table I. Histologic type of 191 oral nevi (70 cases
We have also included in the present review three from UCSF studies and 121 cases from the litera-
casesof junctional nevus from the study of Trodahl ture)
and Sprague,” the details of which were given by L’CSF
other authors.ls Thus, a total of 121 cases from the Tj,pe rrudies Literalwe Tortrl 1’6,
literature (excluding those from UCSF) were avail-
able for evaluation. Intramucosal II 64 I05 55
Compound 5 I I? 6
Combining all available data on oral nevi-from
Junctional -I 6 IO 5
UCSF and from the literature-provided a total of Common blue 18 13 61 31
191 casesfor analysis. From these cases,we compiled Combined -2 1-32
the following information: the histologic type of the Total 70 121 191 100
nevus; the location; the size; the color (clinically
pigmented or nonpigmented); the configuration (ele-
vated or flat); the duration; the patient’s age, gender,
and race; and the clinical diagnosis of the contribu- rarity of oral nevi in general, it may be difficult to
tor. Not all details were available for every case gather casesof nevi in significant numbers.
accepted. No conclusions with respect to the combined nevus
could be drawn becauseof the small number found.’
RESULTS AND COMMENTS Analysis of this type will have to wait until additional
Histologic type of nevi
oral casesare reported.
The histologic classification of the 191 nevi is
Location
shown in Table I. One hundred five (55%) nevi were
of the intramucosal type, and sixty-one (32%) were Table II shows the location of the nevi. The most
common blue nevi. The twelve (6%) compound and common site was the hard palate, followed by the
ten (5%) junctional nevi were relatively uncommon, buccal mucosa, the vermilion border, the gingiva,
and the three (2%) combined nevi were found to be and the labial mucosa. Few nevi were found in the
the rarest of all. No acceptable casesof oral cellular retromolar pad and in the soft palate. One lesion was
blue nevus were found in the literature. Esguep and located on the tongue. No lesions were found in the
coworkers’1 mention that one of their blue nevi floor of the mouth.
exhibited features of the cellular type, but they did The hard palate was the predominant location for
not document their findings well enough to enable us the blue nevus, as 69% were identified in this area.
to consider their report in our review. No cases of This site was followed by the labial mucosa and the
oral Spitz nevus (also known as benign juvenile vermilion border (each 11.5%), and by the soft
melanoma or spindle and epithelioid cell nevus) were palate and the buccal mucosa (each 3.5%). Only one
found in the literature. blue nevus was in the gingiva.
The finding of 61 oral common blue nevi out of a In contrast to the findings associatedwith the blue
total of 191 nevi was of considerable interest because nevus, the most common location for the intramuco-
this type of nevus has been considered relatively sal nevus was the buccal mucosa (28.5%), followed
uncommon on the skin in relation to melanocytic nevi by the hard palate (23%), the gingiva (17%), the
(intradermal, compound, and junctional).5 Whereas vermillion border (14.5%), the retromolar pad
the blue nevus constituted 26% of the total nevi in the (6.5%), and the labial mucosa (5.5%). Few nevi were
studies from UCSF, the figure in the surveyed located in the soft palate (4%), and one nevus was
literature was even higher-36%. Whereas the fre- located in the ventral tip of the tongue. To our
quency of the common blue nevus is indeed higher in knowledge, this is the first reported nevus in this
the oral cavity than in the skin, the percentage found location.
in the surveyed literature may be excessively high. If The twelve compound nevi were almost equally
so, it may be that there is a tendency to report what distributed between the buccal mucosa (five nevi)
are considered to be “rare” nevi, like the common and the hard palate (four nevi), with single nevi
blue nevus, rather than the intramucosal nevus, located in the gingiva, in the labial mucosa, and in
which is considered to be more common. It may be the retromolar pad.
possible to determine the true frequency of the Seven junctional nevi were located in the hard
various types of oral nevi if prospective studies are palate. Two were found in the vermilion border and
analyzed and published. Because of the relative one was found in the buccal mucosa.
676 Buchner and Hansen Oral Surg.
June. 1987

Table II. Location of 191 nevi (70 cases from UCSF studies and 121 casesfrom the literature)
Location Intramucosal Compound Junctionul l-oral (7 I

Hard palate 21 -I 7 7s 41 .o
Buccal mucosa* 30 5 I 3x 30.0
Vermilion border? 15 2 Z-1 13.5
Gingiva$ 18 I 21 11.5
Labial mucosa 6 I I4 7.5
Retromolnr pad 7 1 R 1.0
Soft palate 4 h 3.0
Tongue -! -! 0.5
Total 105 Ir lo 191 100.0

*Including locations designated as mucobuccal rold.

flncludlng 7 GMS from the literaturr where the locatwn wa, designated as “lip.”
tlnclud~ng locations designated as alveolar ridge.

Table Ill. Type of 191 nevi by gender of patients (70 cases from UCSF studies and 121 cases from the
literature)
Intramucosal Compound Junctional Blue Combined Total ( 06 !

Male 38 3 .i 29 I 17 40
Female 67 s 2 112 2 fi 60
Total 105 I’ IO 61 3 I91 I00

Of three combined nevi, two were located in the years, respectively) and for patients with blue nevi
gingiva and one was located in the hard palate. was relatively high (38.0 years). The mean age for
patients with intramucosal nevi was 35.3 years.
Gender of patients
The age distribution is shown in Table V. The
The gender of patients with oral nevi is shown in highest incidence was in the third and fourth
Table III. The female-to-male ratio was 1.5:l. The decades, and almost half of the patients (49.2%)
105 intramucosal nevi were more common in female were in those age groups. The intramucosal nevus as
patients (64%). The 6 1 blue nevi were almost equally well as the blue nevus showed the highest incidence
distributed between male patients (48%) and female in these decades.
(52%). Eight of the twelve patients with compound Melanocytic nevi of the skin are only rarely
nevi were female and four were male. The ten present at birth. Most nevi appear in childhood,
junctional nevi were equally distributed between the adolescence,and early adulthood, and with advanc-
sexes. ing age there is a progressive decreasein the number
of melanocytic nevi. I9 The evolution and regression
Age of patients
of melanocytic nevi correlate with their histologic
At the time of excision, the age of the patients appearance. Junctional proliferation of nevus cells is
ranged from 3 years for the youngest patient to 85 present in almost every melanocytic nevus in chil-
years for the oldest patient (Table IV). The age dren, in about half of the nevi in young adults, and in
range of patients with intramucosal nevi was 9 to 85 only 10% to 20% of the nevi in adults more than 50
years, whereas the age range of patients with com- years of age.19.?0In contrast, intradermal nevi are
pound and junctional nevi was 5 to 50 years and 3 to most unusual in the first decade of life, and their
54 years, respectively. The age range was 5 to 78 proportions increase progressively with age.”
years in patients with blue nevi. Considering these findings, it was of interest that
A breakdown of mean ages according to types of although we analyzed only a small number of junc-
nevi is shown in Table IV. The mean age for all tional and compound nevi, two junctional nevi were
patients combined was approximately 35 years; male discovered in patients at the age of 50 and 54 and one
patients on the average tended to be older (37.7 compound nevus was diagnosed at the age of 50. On
years) than female patients (33.0 years). the other hand, one intramucosal nevus was discov-
The mean age for patients with compound and ered in a 9-year-old child.
junctional nevi was relatively low (22.2 and 24.1 We had the opportunity to observe progression
Volume 63 Pigmented nevi of oral mucosa 679
Number 6

Table IV.Age range and mean age (years) of 187 patients (69 cases from UCSF studies and 118 cases
from the literature)
Intramucosal Compound Junctional Blue Combined Total

Age range (yr) 9-85 j-50 3-54 5-78 36-U 3-85

Mean age (yr)
Male 37.6 29.0 20.4 41.5 44.0 31.1
Femalc: 33.9 19.8 27.8 34.9 36.5 33.0
Male and female ZT F5
_b..- 21.1 38.0 39.0 34.9
-__

Table V. Age distribution of 187 patients (69 cases from UCSF studies and 118 casesfrom the literature)
Age (p-l Intramucosal Compound Junctional Blue Combined Total (“cl
/
o-9 I 2 2 1 6 3.2
IO-19 II 3 I 7 22 11.8
20-29 17 3 4 I4 48 25.1
30-39 28 I I I2 2 44 23.5
JO-49 I5 I II I 28 15.0
50-59 I3 I 3 6 22 I I.8
60-69 6 5 II 5.9
70-79 5 5 2.7
80-89 I I *
Total 102 ii ii3 61 J I87 100.1
-

Table VI. Race of 132 patients (61 cases from UCSF studies and 71 casesfrom the literature)
Intramucosal Compound Junctional Blue Combined
Race LKSF Literature UCSF Literature UCSF Literature L’CSF Literature UCSF Literature Total , “r, J

White I8 20 3 I I 4 8 II I 73 55.3
Black 6 I’ I I I 8 I 30 22.7
Asian 9 3 I 4 I I 19 14.4
Hispanic 2 I I 2 I 2 9 6.8
American
Indian .A -! 0.8
Total ,s 36 5 r 3 s Is 21 r T 132 100.0

with age of a compound nevus to an intramucosal proportion of Asian and Hispanic patients (14.4%
nevus in one of the patients in the UCSF studies. and 6.8%, respectively) may be due to the large
With the patient at 11 years of age, an incisional number of Asian and&Hispanic persons in the San
biopsy of a pigmented area revealed a compound Francisco Bay Area, from which most of the UCSF
nevus and, at 15 years of age, a repeat biopsy patients came.
revealed that the lesion had converted to an intramu-
Clinical features of the nevi
cosal nevus.
Size. Size of the nevi was known in 133 cases
Race
(Table VII). Size, given as the lesion’s largest
Race was reported in 132 cases,and the distribu- dimension, ranged from 0.1 cm for the smallest to 3.0
tion according to the various types of nevi is shown in cm for the largest. The mean size was.0.5 cm. Oral
Table VI. Oral nevi were found in whites, blacks, nevi were small. Almost half ranged from 0.1 to 0.3
Asians, Hispanics, and American Indians. They were cm and more than one fourth ranged from 0.4 to 0.6
reported more frequently in whites (55.3%) than in cm. Large nevi of 1.3 cm and greater constituted
blacks (22.7%), but considering the proportion of the only 6.0% of the nevi.
black population in the United States this percentage The blue nevi were smaller than the intramucosal
appears higher than expected. The relatively high nevi; almost 88% were from 0.1 to 0.6 cm in size, as
680 Buchner and Hansen Oral Surg.
June, 1987

Table VII. Size of 133 nevi (52 casesfrom UCSF studies and 81 casesfrom the literature)
, __~
Size (cttz~ Tlntramucosal Compound Junctional Blue Cotnbined Total (7 1

0.1-0.3 33 ? 3 2‘l 6’ 46.6

0.3-0.6 16 I 1 19 3x 28.6
0.7-o.‘) 6 ? x 6.0
I .o- I .z 8 3 2 ? 1 17 I’.8
Greater than 1.3 1 L L -3 6.0
Total 68 7 7 49 ? 133 100.0

Table VIII. Clinical pigmentation of 176 nevi (70 cases from UCSF studies and 106 casesfrom the
literature)
Inrramucosal Compound Junctional Blue Combined Total (%‘ol

Pigmented 73 9 IO 59 3 151 x7
Nonpigmented 20 -! -! 11 13
Total 93 10 -ii 60 ; 176 100

compared with 72% of the intramucosal type. Blue
nevi ranged in size from 0.1 to 1.5 cm, with a mean of
0.44 cm, but almost half were between 0.1 and 0.3
cm. The size of intramucosal nevi ranged from 0.1 to
3.0 cm with a mean of 0.46 cm and, again, almost
half were between 0.1 and 0.3 cm.
The sizes of only a few compound and junctional
nevi were known. The size range for compound nevi
was 0.2 to 1.5 cm with a mean of 0.8 cm; that of the
junctional nevus was 0.2 to 1.Ocm with a mean of 0.5
cm. Becauseof the small number of the two lesions,
these figures must be interpreted with caution.
Melanocytic nevi of the skin have been classified
in a variety of ways. One of the classifications is
according to their presenceat birth or their develop-
ment after birth. Nevi that are present at birth are
termed congenital melanocytic nevi, and those that
develop after birth are referred to as acquired nevi.
Histologically, both types may be junctional, com-
pound, or intradermal. Congenital melanocytic nevi
may be as small as a few millimeters in diameter, or
they may be so huge that they cover nearly the entire
body of a newborn infant. In between the ex-
tremes, there are lesions of different sizes. In con-
trast to most congenital nevi, all acquired melanocyt-
ic nevi tend to be small, usually not greater than 0.6
cm in diameter. It is unusual to seeacquired melano-
cytic nevi that are as large as 1.0 cm or more in
size.?’
With this information taken into consideration, it
is conceivable that the large oral nevi encountered in
our study represent examples of congenital melano-
cytic nevi of the oral cavity.
Clinical pigmentation. Information with respect to
clinical pigmentation was available for 176 nevi. The
color was described as gray, brown, blue, black
(dark), or various combinations of these. The pres-
ence or absenceof clinical pigmentation is shown in
Table VIII. Nonpigmented nevi were especially com-
mon in the intramucosal group, in which 22% did not
exhibit clinical pigmentation. On the other hand, all
but one blue nevus, as well as all but one compound
nevus, were pigmented (usually blue or blue-black).
All 10 junctional nevi were pigmented. The fact that
almost one fourth of the nevi of the intramucosal
type were clinically nonpigmented is of importance
in the clinical differential diagnosis of oral lesions,
since inexperienced clinicians may fail to consider
pigmented nevi in their differential diagnosis.
Configuration. The nevi were described as well
circumscribed, as round or oval, and as flat, slightly
raised, or raised. Some were also described as elevat-
ed nodules or as polypoid masses.Most were sessile,
and only a few were pedunculated. Most had a
smooth surface, and only a few showed a rough,
verrucous, or papillomatous surface. The configura-
tion of the nevi was reported for 142 cases and is
shown in Table IX. More than two thirds were
described as “slightly raised” or as “raised,” and the
remaining lesions were “flat.” Almost 80% of the
intramucosal lesions were raised, whereas only 64%
of the blue nevi and 67% of the compound nevi were
raised. All junctional nevi were flat and all nonpig-
mented lesions were raised. The finding that most
oral nevi are raised lesions is helpful in the differen-
tial diagnosis of nevi from other pigmented lesions
such as physiologic (racial) pigmentation, oral mela-
notic macule, and amalgam tattoo, which are almost
always fiat lesions. On the other hand, it is important
to remember that since almost one third of the oral
Volume 63 Pigmented nevi of oral mucosa 661
Number 6

Table IX. Configuration of 142 nevi (56 casesfrom UCSF studies and 86 casesfrom the literature)
Intramucosal Compound Junctional Blue Combined Total (%I

“Raised” 62 6 30 1 99 70
“Flat” 16 3 6 .!.I I 33 30
Total 78 9 6 47 2 142 100

Table X. Duration of 67 nevi (37 casesfrom UCSF studies and 30 casesfrom the literature)
Reported duration Intramucosal Compound Junctional Blue Combined Total

“Weeks”* 8 1 2 II
“Months”? 4 1 1 2 8
“Several years”* I2 1 I 8 I 23
“Many years”§ 13 5 18
“Since birth” 1 I -2 1
Total 40 4 2 20 7 67

*Including spec~ticduration of several days to 7 weeks.

tlncluding specific duration of 2 to I I months.
$lncluding specific duration of I to 9 years.
§lncluding \pec~iic duration of IO years or more.

nevi are flat, the latter cannot be differentiated on a
clinical basis from the macular pigmented lesions
that have been mentioned nor from malignant mela-
noma in situ.
Duration. Relatively few patients were able to give
information with respect to the duration of the lesion.
Since most oral nevi were asymptomatic and were
detected during routine dental examination, and
since many were located in posterior oral regions, it
was not surprising that for most patients the duration
of the lesion was “unknown.” In 67 cases, the
patients had submitted, upon questioning, some
information that was usually in general terms such as
“weeks,” “months,” “several years,” “many years,”
and “since birth” (Table X). Only in a relatively few
cases-usually for lesions in the anterior portion of
the oral cavity-+ould the patient recall an exact
figure. In other cases,the information given by some
of the patients should be considered speculative.
Clinical diagnosis and differential
A variety of clinical diagnoses were made by the
clinicians who submitted the biopsy material, and in
certain cases more than one diagnosis was consid-
ered. For the clinically pigmented lesions, the most
common diagnosis was nevus, followed in decreasing
order by amalgam tattoo, oral melanotic macule
(under various terms such as focal melanosis or
ephelis), and hemangioma. In a few cases, the
diagnosis of foreign material (such as graphite),
hematoma, varix, mucocele, or lentigo was submit-
ted. For the clinically nonpigmented lesions, fibroma
and papilloma were the most common diagnosis. In a
few cases,ectopic sebaceouscyst and salivary gland
neoplasm were also considered.
Malignant melanoma was considered the sole
clinical diagnosis in seven casesand was included in
the differential diagnosis of an additional twenty-one
cases.
Nevi and melanoma
It has long been recognized that melanomas of the
skin are frequently associated with preexisting pig-
mented lesions. At one time, it was believed that the
majority of melanomas arose from nevi showing
proliferative activity at the dermal-epidermal junc-
tion.22 This view is not held today. The precise re-
lationship between nevi and melanoma has never
been clearly established becausegrowth of neoplastic
cells destroys the original nevus and because the
patient’s history is often unreliable. In a large series
of early melanomas, a preexisting melanocytic nevus
was recognized in about half of the patients.23
diagnosis
Despite the imputed association of melanocytic
nevi of the skin with melanoma, it is clear that most
nevi remain innocent throughout life-indeed, the
natural history of nevi is to proceed to complete
clinical regression in old age.19If 50% of melanomas
arise in nevi and if the average number of nevi per
individual is 20, then the annual incidence of mela-
noma of the skin in a high-risk area such as Queens-
land, Australia (approximately 20 cases per
100,000) is one in 200,000 nevi. These considerations
would suggest that prophylaxis of melanoma cannot
be achieved through surgical removal of nevi, unless
means can be found to identify clinically those
682 Buchner and Hansen
specific lesions, if any, that are at increased risk for
malignant change.2J
The blue nevus, regardless of site, rarely shows
malignant transformation, and in the unusual
extraoral malignant blue nevus, the maternal lesion
is of the cellular type, not of the common type.?
One might infer from findings in skin that a
relationship may exist between melanocytic mucosal
nevi and melanoma. Although the natural histories
of oral and skin nevi may be similar, this assumption
is by no means certain. 26The potential for oral nevi
to undergo malignant transformation is unknown
because of the small number of reported cases and
limited follow-up.‘, 5
Not all oral pigmented lesions, however, are mela-
nocytic nevi or melanoma. Often the diagnosis of
melanocytic pigmentation such as is seen in racial
pigmentation, Peutz-Jeghers syndrome, and Addi-
son’s diseasecan be made on the basis of history and
clinical findings. In these cases, removal of the
lesions is not necessarysince there is no evidence that
the lesions are premalignant. Similarly, the diagnosis
of some nonmelanotic pigmentation such as that
resulting from endogenouspigment (e.g., hemosider-
in) and from exogenous pigmentation (from dental
materials, graphite, and other foreign materials) can
often be made on the basis of history and on clinical
grounds, and removal may not be necessary, except
to confirm the diagnosis.
Review of the literature revealed that in about one
third of the patients with oral melanoma, preexisting
macular pigmentation was present for a variable
period of time.*’ We don’t know if these pigmented
areas represented preexisting melanocytic nevi or
were a manifestation of malignant melanoma in situ.
Therefore, we recommend that all pigmented lesions
not otherwise diagnosed be removed. For skin le-
sions, this is not practical, but oral lesions are so
uncommon that for the present, excision seems
advisable.
We thank Ms. Evangeline Leash for editing and Ms.
Teresita Arenas for processing the manuscript.
REFERENCES
I, Buchner A, Hansen LS. Pigmented nevi of the oral mucosa: a
clinicopathologic study of 36 new cases and review of I55
cases from the literature. Part I: A clinicopathologic study of
36 new cases. ORAL SURG ORAL MED ORAL PATHOL 1987:
63~566-72.
2. Buchner A. Hansen LS. Pigmented nevi of the oral mucosa: a
clinicopathologic study of 32 new cases and review of 75 cases
from the literature. Part I: A clinicopathologic study of 32
cases. ORAL SURG ORAL MED ORAL PATHOL 1979;48:13 I-
42.
3. Hansen LS, Buchner A. Changing concepts of the junctional
nevus and melanoma: review of the literature and report of
case. J Oral Surg I98 1:39:96 l-5.
Oral Surg.
June, 1987
4. Ficarra G, Hansen LS, Engebretsen S, Levin LS. Combined
nevi of the oral mucosa. ORAL %RC ORAL MED ORAL PATHOI
(In press.)
5. Buchner A. Hansen LS. Pigmented nevi of the oral mucosa: II
clinicopathologic study of 32 new cases and review of 75 cases
from the literature. Part II: Analysis of 107 cases. OR.N SURG
ORAL MED ORAL PATHOL 1980;49:55-62.
6. Gray RLM. Pigmented lesions of the oral cavity. J Oral Surg
I978;36:950-5.
7. Mader CL, Konzelman JL. Blue nevus of the oral cavity. Gen
Dent 1978;26:66-7.
8. Pillai RR. intraoral intramucosal nevus. J Indian Dent Assoc
1979;51:215-6.
9. Devildos LR, Langlois CC. lntramucosal cellular nevi. ORAL
SURC ORAL MED ORAL PATHOL I98 I;52 162-6.
IO. Levin LS, Cameron SC. Intradermal nevus of the buccal
mucosa: a case report. J Md State Dent Assoc 1982;25:56-
1.
I I. Wescott WB, Correll RW. Palpable, elevated, pigmented
nodule in the palate. J Am Dent Assoc 1982;105:248-50.
12. Lovas CL, Wysocki GP, Daley TD. The oral blue nevus:
histogenetic implications of its ultrastructural features. ORAL
SURG ORAL MED ORAL PATHOL 1983;55:145-59.
13. Bochlogyros PN, Markopoulos A, Kanakis P. lntradermal
nevus of the oral mucosa. Quintessence lnt 1983:14:499-
501.
14. Esguep A, Solar M, Encina AM, Fuentes G. Primary
melanotic alterations in the oral cavity. J Oral Med 1983:
4:141-6.
15. Watkins KV, Chaudhry AP. Yamane GM. Sharlock SE.
Jain R. Benign focal melanotic lesions of the oral mucosa. J
Oral Med 1984;39:91-6, 118.
16. Papanicolaou SJ, Pierrakou ED, Patsakas AJ. Intraoral blue
nevus. J Oral Med 1985;40:32-5.
17. Trodahl JN. Sprague WC. Benign and malignant melanocyt-
ic lesions of the oral mucosa: an analysis of I35 cases. Cancer
1970;25:812-23.
18. Gossman JR, Miller A. Intraoral junctional nevus: review of
the literature and report of case. J Oral Surg 1975;33:275-
XI.
19. Stegmaier OC. Natural regression of the melanocytic nevus. J
Invest Dermatol 1959;32:413-20.
20. Maize JC, Foster G. Age related changes in melanocytic
naevi. Clin Exp Dermatol 1979;4:49-58.
21. Roses DF. Harris MN, Ackerman AB. Diagnosis and man-
agement of cutaneous malignant melanoma. Philadelphia:
WB Saunders Co. 1983:3-14.
22. Sober AJ. Fitzpatrick TB. Mihm. MC Jr. Primary malignant
melanoma of the skin: recognition and management. J Am
Acad Dermatol 1980;2:179-97.
23. Sagebiel RW. Histopathology of borderline and early malig-
nant melanomas. Am J Clin Pathol 1979:3:543-52.
24. Elder DE, Greene MH. Bondi EE. Clark. WH Jr. Acquired
melanocytic nevi and melanoma. In: Ackerman AB, ed.
Pathology of malignant melanoma, New York: Masson Pub-
lishing GSA, Inc.-1981:185-215.
25. Batsakis JG. Reeezi JA. Solomon AR. Rice DH. The
pathology of head land neck tumors: mucosal melanomas, part
13. Head Neck Surg 1982;4:404-18.
26. Weathers DR. Benign nevi of the oral mucosa. Arch Derma-
tol 1969;99:688-92.
27. Rapini RP, Golitz LE, Greer RO. Krekorian EA, Poulson T.
Primary malignant melanoma of the oral cavity: a review of
177 cases. Cancer 1985;55:1543-5 I.
Reprinr requesrs to:
Dr. Louis S. Hansen
Division of Oral Pathology
School of Dentistry
University of California
San Francisco, CA 94143-0424