Condyloma Acuminatum
Etiology
• A sexually transmitted disease
• Associated with human papillomavirus (HPV) types 6, 11, 16, and 18 most often
• Can result in autoinoculation of other sites via trauma
• Lesions located at the site of contact/traumatic event
Clinical Presentation
• Usually on nonkeratinized tissues in immunocompetent patients (soft palate, lingual frenum)
• Pink to whitish pink, exophytic papillary growths with pedunculated outline
• May be solitary or multiple and variably sized, up to 2 to 3 cm
• Can present as papillomatosis of upper respiratory tract
Diagnosis
• Location and appearance
• Demonstration of koilocytotic cellular changes on biopsy
• In situ hybridization or polymerase chain reaction reveals specific HPV subtype
• Electron microscopy demonstrates intranuclear virions
Differential Diagnosis
• Focal epithelial hyperplasia
• Multiple intraoral verruca vulgaris
• Squamous papilloma
Treatment
• Conservative removal
• Conventional surgery
• Laser ablation
• Topical podophyllin
Prognosis
• Recurrences common
• Contagiousness and autoinoculation are considerations.
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| Condyloma Acuminatum |
Focal Epithelial Hyperplasia
Etiology
• A viral infection (HPV 13 or 32), usually found in childhood
• Familial/ethnic clustering often noted, probably secondary through horizontal viral transmission
• Often occurs in native Americans
Clinical Presentation
• Numerous, slightly raised whitish pink asymptomatic papules and irregular plaques that may become confluent
• Size of lesions ranges from a few millimeters to coalescent papules several centimeters in dimension
Microscopic Findings
• Well-defined acanthotic features
• Broadened, anastomosing epithelial ridges with occasional superficial koilocytotic changes
Diagnosis
• Multiple, characteristic lesions
• Biopsy findings
• In situ deoxyribonucleic acid hybridization to demonstrate HPV subtype
• Ultrastructural localization of intranuclear virions
Differential Diagnosis
• Condyloma acuminatum
• Multiple verruca vulgaris
Treatment
• None; lesions usually regress spontaneously
• Excision if esthetic needs demand
• Intralesional interferon therapy
Prognosis
• Excellent
• No reported malignant transformation
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| Focal Epithelial Hyperplasia |
Keratoacanthoma
Etiology
• Unknown, may be related to several factors, as follows:
• Viral—HPV subtypes 11, 13, 24, 33, 57
• Altered expression of cell cycle proteins including cyclin E, p53, PCNA
• Keratinocyte dedifferentiation reflected in deficient desmoglein production
• Immunosuppression
• Sun damage
• May represent a highly differentiated form of squamous cell carcinoma
• May indicate underlying alimentary neoplasia (Muir-Torre syndrome)
Clinical Presentation
• Usually solitary on sun-exposed areas, including lip
• Initially erythematous papule
• Rapid growth over 4 to 8 weeks
• Nodular, hemispheric, firm nodule
• Central keratin core
• Occasionally regresses spontaneously
• Extremely rare intraorally
Diagnosis
• Clinical evaluation, follow-up
• Histopathology shows keratin plus normal, peripheral epidermis and mature, premature keratinization; no invasion below adnexa; marked pseudoepitheliomatous hyperplasia
Differential Diagnosis
• Squamous cell carcinoma
• Molluscum contagiosum
• Warty dyskeratoma
• Verruca vulgaris
• Pilomatricoma
• Condyloma acuminatum
• Squamous papilloma
Treatment
• Observation and careful follow-up
• Local excision
• Cryotherapy
• Intralesional chemotherapy (methotrexate, 5-fluorouracil, or
bleomycin)
Prognosis
• Excellent
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| Keratoacanthoma |
Lymphangioma
Etiology
• A benign proliferation of lymphatic vasculature
• Usually congenital in nature
Clinical Presentation
• Superficial or deep in location
• Typically waxes and wanes in size
• Most commonly involves the tongue followed by lips, buccal mucosa, palate
• Facial asymmetry may be a presenting sign.
• Superficial mucosal lymphangiomas resemble caviar or frog’s eggs.
• Deeper lesions present as painless fluctuant masses such as macroglossia.
• Often combined with blood vessels
• Rare variant may occur bilaterally on mandibular alveolar ridge of neonates
Diagnosis
• Biopsy
• Lymphangiography
Differential Diagnosis
• Neurofibroma (deep)
• Hemihypertrophy syndromes
Treatment
• Excision
• If large lesions are stable, observation
• Sclerotherapy
Prognosis
• Variable, depending upon depth and extent of lesion
• Cavernous variant has guarded prognosis
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| Lymphangioma |
Papillary Hyperplasia (Palatal Papillomatosis)
Etiology
• Generally attributed to ill-fitting maxillary denture
• Often associated with 24 h/d denture wearing
• Candida albicans overgrowth common
• May be noted in habitual mouth breathers (nondenture wearers)
Clinical Presentation
• Erythematous palatal vault beneath denture
• Nodular papillary excrescences
• Generally asymptomatic
Diagnosis
• Clinical appearance
• Biopsy results show fibrous and epithelial papillary hyperplasia; may note pseudoepitheliomatous hyperplasia
Differential Diagnosis
• Contact stomatitis
• Chronic candidiasis
• Denture stomatitis
Treatment
• Establishment of good oral hygiene
• Possible antifungal therapy
• Surgical removal of affected mucosa, if excessive tissue hyperplasia
• Relining/remaking of denture
Prognosis
• Excellent
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| Papillary Hyperplasia (Palatal Papillomatosis) |
Pyostomatitis Vegetans
Etiology
• A pustular eruption usually associated with inflammatory bowel disease and skin disease
• Liver dysfunction (sclerosing cholangitis) may be associated in some cases.
Clinical Presentation
• Mucosal pustules, erythema, edema
• Erosions and ulcers may form with serpiginous outlines (“snail tracks”).
• Folds of nodular to hyperplastic tissue (“cobblestoning”)
Microscopic Findings
• Neutrophilic and eosinophilic infiltrate into epithelium producing microabscesses
• Infiltration between epithelial clefts
• Epithelial hyperplasia
Diagnosis
• Correlation with underlying gastrointestinal disease, such as the following:
• Ulcerative colitis
• Crohn’s disease
• Sclerosing cholangitis
• Malabsorption syndrome
Differential Diagnosis
• Oral Crohn’s disease
• Pseudomembranous (acute) candidiasis
• Melkersson-Rosenthal syndrome
• Orofacial granulomatosis
• Acanthosis nigricans
Treatment
• Successful management of underlying gastrointestinal disease
• Local anti-inflammatory agents
• Dapsone or sulfapyridine systemically
Prognosis
• Correlates with that of systemic disease
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| Pyostomatitis Vegetans |
Squamous Papilloma
Etiology
• A benign epithelial proliferation
• HPV is found in most cases; several subtypes have been identified, especially HPV 6 and 11.
Clinical Presentation
• Exophytic, papillary mass, measuring less than 1 cm
• Usually pedunculated and soft in texture
• White
• Usually solitary; may be multiple
• Favors soft palate; uvula, tongue, gingiva, buccal mucosa may also be involved
Microscopic Findings
• Epithelial hyperplasia with fibrovascular cores
• Papillary projections may be sharp to blunt.
• Epithelium may be dysplastic in some lesions from human immunodeficiency virus–positive patients.
Diagnosis
• Clinical appearance
• Biopsy features
Differential Diagnosis
• Condyloma acuminatum
• Verruca vulgaris
• Focal epithelial hyperplasia
• Verrucous carcinoma
Treatment
• Surgical excision
Prognosis
• Low recurrence rate
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| Squamous Papilloma |
Verruca Vulgaris (Oral Warts)
Etiology
• Infection of mucosal epithelium by members of the human papillomavirus group—usually HPV 2, 4, 6, or 11
Clinical Presentation
• Papular to nodular and exophytic appearance
• Surface texture is cauliflower-like or verruciform in nature
• Perioral skin lesions may be brownish.
• Oral mucosal lesions are usually white to pink.
• May be pedunculated or broad based
• Intraoral sites of predilection include the lips, palate, and attached gingiva.
• Multiple oral lesions may be evident in immunocompromised patients.
Microscopic Findings
• Surface hyperkeratosis
• Granulosis
• Koilocytosis
• Acquired immunodeficiency syndrome–associated oral warts may appear dysplastic microscopically.
Diagnosis
• Clinical appearance
• Microscopic findings
• Immunohistochemical demonstration of HPV common antigen
Differential Diagnosis
• Focal epithelial hyperplasia
• Keratoacanthoma
• Papillary squamous carcinoma
• Squamous papilloma
• Condyloma acuminatum
Treatment
• Excision
• Laser surgery
• Cryosurgery
• Electrosurgery
Prognosis
• Excellent in immunocompetent host
• Recurrence not uncommon
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| Verruca Vulgaris (Oral Warts) |
Verrucous Carcinoma
Etiology
• A well-differentiated, exophytic and endophytic squamous cell carcinoma often associated with tobacco use, especially smokeless tobacco
• A primary or ancillary role for HPV is suspected.
• May be preceded by keratotic patch (see “Verrucous
Hyperplasia” on page 158)
Clinical Presentation
• One-half of cases involve the buccal mucosa.
• Attached gingiva is involved in one-third of cases.
• Early, superficial lesions often are interpreted as verrucous hyperplasia; lesions become exophytic, irregular, and indurated.
• Advancing lesions push into adjacent tissues.
• Late lesions invade the periosteum and destroy bone.
• Metastases are rare.
Microscopic Findings
• Well-differentiated, blunt masses of epithelium extending into submucosa
• Intense lymphocytic infiltrate adjacent to invasive front
Diagnosis
• Microscopic findings
• Full-thickness specimen is necessary to establish diagnosis
Differential Diagnosis
• Verrucous hyperplasia
• Papillary squamous cell carcinoma
• Proliferative verrucous leukoplakia
Treatment
• Wide excision
• Radiation therapy may be effective.
• Dedifferentiation may occur spontaneously or after radiation therapy.
Prognosis
• Excellent
• Local recurrence is a distinct possibility.
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| Verrucous carcinoma |
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| Verucous carcinoma |
Verrucous Hyperplasia
Etiology
• Unknown; tobacco (smokeless) associated most commonly
• Role of HPV is unclear.
• A possible precursor to verrucous carcinoma
Clinical Presentation
• Exophytic, papillary, keratotic fronds of epithelium
• May be part of the proliferative verrucous leukoplakia spectrum
Microscopic Findings
• Papillary to verruciform surface projections
• Keratin varies in thickness
• Broad, bosselated epithelial ridges
• Well-differentiated cellular features
• Some similarity to early verrucous carcinoma
Diagnosis
• Microscopic features
Differential Diagnosis
• Verrucous carcinoma
• Papillary squamous cell carcinoma
• Proliferative verrucous leukoplakia
Treatment
• Excision or ablation (eg, laser, electrocautery)
• Continued observation
Prognosis
• Good with complete excision
• Recurrence is common.
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| Verrucous Hyperplasia |
