Sections

Treatment

Medical Care

Peutz-Jeghers syndrome

Medications are directed toward the GI aspects of the disease. No medications are directed specifically for treatment of the oral lesions.

Amalgam tattoos

No medication or treatment is necessary.

Melanoma

Medical therapy is not often beneficial for oral melanoma. Chemotherapeutic medications for the treatment of oral melanoma do not reliably reduce the tumor volume.

Aggressive surgery remains the treatment of choice.

Interferon, dacarbazine, and BCG vaccine have been tried with marginal and unpredictable results.

Drug therapy (dacarbazine), therapeutic radiation, and immunotherapy are used in the treatment of cutaneous melanoma, but they are of questionable benefit to patients with oral melanoma. Dacarbazine is not effective in the treatment of oral melanoma; however, dacarbazine administration in conjunction with interleukin 2 may have therapeutic value.

Experience with oral malignant melanoma (OMM) is largely derived from single cases. Anecdotal reports have described success with interferon alfa or hyperfractionated radiation therapy. Many cancer centers follow surgical excision with a course of interleukin 2 as adjunctive therapy to prevent or limit recurrence.^[84]

Because of the rarity of the lesions, assembling a cohort study group to evaluate the different therapeutic regimens is difficult.

Protocols with interferon and other immunotherapies are being investigated. A good direction for future research would be to incorporate multimodal therapy.

Peutz-Jeghers syndrome

Push enteroscopy and intraoperative enteroscopy with polypectomy can be used to effectively treat and defer the need for repeated small bowel resections in some patients.

Laparotomy and resection, as indicated, should be performed for repeated or persistent small intestinal intussusception or obstruction or for persistent intestinal bleeding.

Surgical treatment for cancers detected by surveillance and diagnosis is indicated.

Melanoma

Excisional surgery with tumor-free margins remains the treatment of choice. Early surgical intervention when local recurrence is detected enhances survival. Approximately 80% of patients with oral melanoma have local disease, and 5-10% of patients present with grossly involved nodes. After complete surgical excision, the locoregional relapse rate is reportedly 10-20%, and 5-year survival rates are clustered around 10-25%, with a reported range of 4.5-48%. McKinnon et al^[85]reported that tertiary care centers have the best results.

Although radiation alone is reported to have questionable benefit (particularly in small fractionated doses), it may be used as an adjuvant when high-fractionated doses are used.

Neither lymphoscintigraphy nor intraoperative blue-dye sentinel node biopsy (eg, selective neck dissection) is useful in predicting drainage patterns in oral melanomas. Anatomic ambiguity appears to preclude consistent assessment of oral lymphatic drainage patterns when this technique is attempted. Surgical lymph node harvesting depends on the identification of positive nodes after clinical or imaging examination. Prophylactic neck dissection (eg, elective neck dissection) is not advocated as a treatment for oral melanoma.

Consultations

For patients with Peutz-Jeghers syndrome (PJS), consult a gastroenterologist familiar with PJS.

For melanoma, consult the following specialists and facilitate their meeting during head and neck tumor boards to plan the best therapy and aftercare for patients with oral melanoma:

Ear, nose, and throat surgeon
Pathologist (eg, dermatopathologist and general surgical, head and neck, or oral and maxillofacial specialist)
Medical and radiation oncologists
Maxillofacial prosthodontists
Speech therapist

The primary concern is to ensure surgical removal; secondary concerns deal with restoring function and cosmesis. If the anatomy restricts ensured removal, medical oncologists and radiation oncologists must provide the most appropriate adjunctive therapy. Maxillofacial prosthodontists can provide advice about the appliances available and the tissue requirements for support and retention. The involved consultants should be aware of the recall schedule to assess patient progress and adaptation.

Peutz-Jeghers syndrome

Close follow-up care is needed for the GI aspects of the disease. Genetic counseling should be offered to families trying to have children. Further outpatient care for patients with PJS includes the following:

Annual physical examination that includes evaluation of the breasts, abdomen, pelvis, and testes
Annual complete blood cell count
Repeated removal of hemorrhagic or large polyps (>5 mm) by endoscopic polypectomy
Surveillance for cancer, possibly including (1) small intestine with small bowel radiography every 2 years; (2) esophagogastroduodenoscopy and colonoscopy every 2 years; (3) ultrasonography of the pancreas yearly; (4) ultrasonography of the pelvis (women) and testes (men) yearly; (5) mammography (women) at ages 25, 30, 35, and 38 years; every 2 years until age 50 years; then annually; and (6) Papanicolaou (Pap) test every 3 years

Amalgam tattoos

No follow-up care is necessary for amalgam tattoos once the diagnosis is determined.

Melanoma

Patients with melanoma must receive close follow-up care involving oncologists, surgical oncologists, radiologists, and dermatologists. In many instances, psychological assistance and intervention is also necessary.

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Media Gallery

Smoker melanosis.
Smoker melanosis.
Melanotic macule.
Melanotic macule.
Melanotic macule.
Oral nevi
Intramucosal nevus.
Blue nevus.
Intramucosal nevus.
Junctional nevus.
Compound nevus.
Blue nevus.
Oral pigmentation of the gingiva due to amalgam tattoo along with photomicrograph.
Photo of oral pigmented lesion from a patient with Peutz-Jeghers syndrome.
Photos of patients with amalgam tattoo.
Physiologic pigmentation; bilaterally symmetrical, ribbon-like, brown band involving maxillary and mandibular facial gingiva.
Amalgam tattoo; well-demarcated, dark gray macular lesion involving mandibular alveolar mucosa.
Amalgam tattoo; radiopaque particles of amalgam may be seen in a dental radiograph.

of 18

Author

Leticia Ferreira, DDS, MS Associate Professor, Department of Diagnostic Sciences, University of the Pacific, Arthur A Dugoni School of Dentistry

Leticia Ferreira, DDS, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Association of Women Dentists, American Dental Association, American Dental Education Association, California Dental Association, San Francisco Dental Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

Jeff Burgess, DDS, MSD (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Talib Najjar, DMD, MDS, PhD Professor of Oral and Maxillofacial Surgery and Pathology, Rutgers School of Dental Medicine

Talib Najjar, DMD, MDS, PhD is a member of the following medical societies: American Society for Clinical Pathology

Disclosure: Nothing to disclose.

Brian J Dorfman, DMD, MD Staff Physician, Department of Oral and Maxillofacial Surgery, University Hospital, University of Medicine and Dentistry of New Jersey

Brian J Dorfman, DMD, MD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons

Disclosure: Nothing to disclose.

Disorders of Oral Pigmentation Treatment & Management

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Amalgam tattoos

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