Verruca Vulgaris and Squamous Papilloma

• Benign Epithelial Lesions can be associated with Human Papillomavirus (HPV)

Benign Epithelial Lesions Associated with HPV

• Benign hyperplastic exophytic proliferations of the oral epithelium can be associated with different subtypes of HPV

Soft Tissue Tumors can be:

• Connective Tissue Tumors
• Fat Tissue Tumors
• Peripheral Nerve Tumors
• Tumors from Vascular Origin
• Vascular and Lymphatic Malformations
• Benign tumors of Muscles

Other Lesion Types

• Soft Tissue Sarcomas
• Metastatic Tumors
• Salivary Gland Neoplasms (Benign and Malignant)
• Reactive Lesions /Inflammatory Salivary Gland Disorders

Other Salivary Gland Pathology

• Learning Objectives for Oral Medicine II - Oral Pathology II
• Analyze and describe benign and malignant oral and maxillofacial soft tissue tumors
• Analyze and describe benign and malignant salivary glands neoplasms and other salivary glands disorders
• Explain the etiology and pathogenesis of oral and maxillofacial soft tissue neoplasms
• Explain the etiology and pathogenesis of salivary glands tumors
• Discuss clinical and histopathological features, and treatment modalities of neoplasms
• Order appropriate laboratory tests
• Interpret and correlate the results of laboratory findings
• Make correct decisions for other diagnostic procedures
• Describe the preventive measures to patient's oral and general health
• Lectures, clinical cases emphasize describing basic oral lesion, patient's signs/symptoms and diagnostic procedures, following algorithms

Types of HPV and Similar Lesions

• HPV
• Squamous Papilloma
• Verruca Vulgaris
• Condyloma Acuminatum
• Multifocal Epithelial Hyperplasia
• Others
• Keratoacanthoma
• Inflammatory Papillary Hyperplasia of the Pal
• Verruciform Xanthoma
• Acanthosis nigricans
• Molluscum Contagiosum (MC virus)

Squamous Papilloma

• Benign, HPV-induced proliferation of stratified squamous epithelium
• Results in a papillary or verruciform mass
• Frequently associated with HPV types 6 and 11
• 3% of all oral lesions submitted for biopsy are squamous papilloma
• 7% to 8% of all oral masses or growths in children are squamous papilloma
• Individuals aged 30 to 50 years old are most often affected
• No significant gender predilection
• Any oral surface may be affected, but the palate, tongue, and lips are common

Key Features

• Clinical Features: soft, painless, pedunculated, cauliflower or wartlike exophytic nodule with fingerlike surface projections
• Projections may be pointed or blunted
• Color may be white, slightly red, or normal, based on the amount of surface keratinization
• Usually solitary
• Usually measures 0.5cm - 5cm
• It is sometimes difficult to distinguish from verruca vulgaris, condyloma acuminatum, verruciform xanthoma, and multifocal epithelial hyperplasia

Other Features

• Extensive coalescing papillary lesions (papillomatosis) of the oral mucosa may be seen in several syndromes and skin disorders, including:
• Nevus unius lateris
• Acanthosis nigricans
• Focal dermal hypoplasia (Goltz-Gorlin syndrome)
• Down syndrome
• Recurrent Respiratory Papillomatosis (RRP) is attributed to HPV 6 and 11 infection
• RRP is a rare and potentially devastating disease of the respiratory tract with a predilection for the larynx
• RRP includes two distinct types: (1) juvenile-onset and (2) adult-onset

Treatment for Squamous Papilloma

• Conservative surgical excision is commonly used
• Laser excision can also be used
• Recurrence is unlike
• No reports of malignant transformation, continuous enlargement, or dissemination to other parts of the oral cavity if left untreated for years

Verruca Vulgaris (Common Wart)

• Focal, benign, HPV-induced hyperplasia of stratified squamous epithelium
• HPV type 2 is typically present
• Contagious and can spread to other parts of a person's skin/mucosa by auto-inoculation
• Clinical Features:
• Most often arises in children
• May develop even into middle age
• Commonly found on the skin of the hands
• Oral mucosal lesions are usually found on the vermilion border, labial mucosa, or anterior tongue
• Appears as a painless papule or nodule with papillary projections or a rough, pebbly surface
• May be pedunculated or sessile
• Oral lesions are almost always white
• Cutaneous lesions may be pink, yellow, or white
• Enlarges rapidly to its maximum size (usually <5 mm)
• Size remains constant for months or years if the lesion is not irritated
• Multiple or clustered lesions are common
• Extreme accumulation of compact keratin on occasion results in a cutaneous horn or keratin horn
• Other cutaneous lesions, including seborrheic keratosis, actinic keratosis, and squamous cell carcinoma, may create a cutaneous horn
• Infrequently develops on oral mucosa is but extremely common on the skin

Treatment and Prognosis of Verruca Vulgaris

• Topical salicylic acid, topical lactic acid, or liquid nitrogen cryotherapy are effective skin verrucae treatments
• Surgical excision is appropriate for atypical clinical presentation cases with an uncertain diagnosis
• Alternative methods treat skin lesions that recur or are resistant to standard therapy:
• Intralesional bleomycin
• Topical or intralesional 5-fluorouracil
• Topical imiquimod
• Photodynamic therapy
• Oral lesions are excised by conservative surgical excision or by laser, extending to the lesion base
• Recurrence is seen in a small proportion of treated cases
• Verrucae will not transform into malignancy without treatment
• Two-thirds will disappear spontaneously within 2 years, especially in children

Condyloma Acuminatum (Veneral Wart)

• HPV-induced proliferation of stratified squamous epithelium of the anogenital region, mouth, and larynx
• 90% of cases are attributed to HPV 6 and 11
• Coinfection with various other HPV types—including the high-risk types 16 and 18—is frequent
• Common sexually transmitted disease (STD) affecting approximately 1% of the sexually active population
• Oral and anogenital condylomata may be present concurrently
• Incubation is ~1 to 3 months, and autoinoculation of additional mucosal sites is possible

Clinical Features of Condyloma Acuminatum

• Oral lesions frequently occur on the labial mucosa, the lingual frenum, and the soft palate
• The average size is 1.0 to 1.5 cm, but oral lesions as large as 3 cm have been reported
• Presents as a pink, sessile, well-demarcated, non-tender exophytic mass with short, blunted surface projections
• The condyloma tends to be clustered with other condylomata
• Oral condylomata are treated with conservative surgical excision
• Laser ablation may be used
• Remove due to contagion, spreading by autoinoculation to other persons
• There is some concern regarding the potential for laser therapy to produce an infectious plume that exposes the surgical team and patient to airborne HPV

Treatment and Prognosis of Condyloma Acuminatum

• Anogenital condylomata infected with HPV 16 or 18 are associated with an increased risk for malignant transformation to squamous cell carcinoma
• Such transformation has not been demonstrated in oral lesions
• A Danish population-based study of individuals with genital condylomata exhibit a long-term increased risk for anogenital, head, and neck cancer
• Explanations for observation include:
• An immunologic predisposition to persistent HPV infection (resulting in increased risk for HPV-related head and neck cancer)
• Behavioral cofactors such as tobacco and alcohol consumption and male homosexual behavior

Multifocal Epithelial Hyperplasia (Heck Disease)

• Initially was reported as "focal epithelial hyperplasia,” but multifocal epithelial hyperplasia is preferred due to the presence of multiple lesions
• Typically attributed to HPV types 13 and 32
• The condition first described in Native Americans and Inuits but has been reported in many populations and ethnic groups

Predispositions

• Predominantly arises in children and adolescents, although adults may be affected
• Affects multiple family members due to genetic susceptibility or HPV transmission between family members
• An association with the HLA-DR4 (DRB1*0404)has been described
• Lower socioeconomic status, crowded living conditions, poor hygiene, malnutrition, and HIV infection are risk factors
• Clinical Features:
• The labial, buccal, and lingual mucosa are the most common sites of involvement, but can occur on gingival, palatal, oral floor/tonsillar tissues
• The papulonodular clinical variant is characterized by pink, smooth-surfaced papules and nodules
  • Common predilection for the buccal mucosa, labial mucosa, and commissure
• Papillomatous clinical variant: white to pale pink, pebbly nodules on the tongue and attached gingiva
• Both variants present small (0.1 to 1.0 cm), discrete, and well-demarcated lesions that coalesce to produce a cobblestone or fissured appearance

Treatment and Prognosis of Multifocal Epithelial Hyperplasia

• Spontaneous regression occurs after months or years
• Conservative surgical excision may be performed for diagnostic/aesthetic purposes or for recurrent trauma lesions
• Lesions also can be removed with carbon dioxide (CO2) laser, or electrocoagulation

Questions about Verruca Vulgaris (common wart) and Squamous Papilloma, including transmission, diagnosis, HPV types, and treatment. Includes questions about clinical presentation, etiology, and appropriate treatments.