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international journal of stomatology
& occlusion medicine
ISSN 1867-2221
Volume 6
Number 3
J. Stomat. Occ. Med. (2013) 6:106-109
DOI 10.1007/s12548-013-0079-6
Squamous papilloma
B.Praveen Kumar, Tanya Khaitan,
P.Ramaswamy, Sreenivasulu Pattipati,
S.Sudhakar & V. R.Geethika
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case study
106 Squamous papilloma
Abstract Squamous papillomas are exophytic masses
of the oral cavity which are most often benign and as-
ymptomatic. ey are innocuous lesions that are nei-
ther transmissible nor threatening. As an oral lesion
they raise concerns because of the clinical appearance,
which may mimic an exophytic carcinoma. e patho-
genesis is related to human papillomavirus but there
is controversy regarding the viral origin. In this article
two cases of squamous papilloma of the oral cavity are
presented.
Keywords: Human papillomavirus, Squamous papillo-
ma, Cauliower-like surface, Koilocytes, Mouth diseases
Introduction
Oral squamous papilloma (OSP) is a benign prolifera-
tion of the stratied squamous epithelium, which results
in a papillary or verrucous exophytic mass induced by
human papillomavirus (HPV; [1]). Oral and oropharyn-
geal squamous cell papillomas occur mainly between 30
and 50 years of age, although they may also occur below
10 years of age. ey represent about 8 % of oral tumors
in children [2]. e sites of predilection for localization
of the lesions include the tongue and soft palate but any
surface of the oral cavity can be aected [1].
e HPV involvement in head and neck carcinogen-
esis was rst proposed in 1983 by Syrjanen et al. [3]. Kre-
imer et al. reported the overall prevalence of HPV in 25 %
of head and neck cancers versus 35.6 % in oropharyngeal
cancer and 23.5 % in oral squamous cell carcinomas [4].
High risk HPV types 16 and 18 are by far the most pre-
dominant types at all sites [5]. is article reports two
cases of squamous papilloma of the oral cavity.
Case report 1
A 35-year-old female patient presented with a pain-
less growth in the roof of the mouth over the past year.
e patient noticed the growth 1 year previously which
started as a small growth, gradually increased in size
over a period of 6 months and attained the present size.
ere was no history of pain, paresthesia or numbness
associated with the growth and no similar lesions were
present elsewhere. e patient claimed to be a smoker
and smoked 8–10 Chuttas per day. Medical, dental,
family and personal histories were inconspicuous and
no other abnormalities were noted on general physical
examination.
Intraoral examination revealed the presence of a soli-
tary, well-dened, oval-shaped and exophytic growth on
the left half of the hard palate (Fig.1) measuring approxi-
mately 0.7 × 0.3cm in size. Anteroposteriorly the growth
extended 2cm behind the incisive papilla to 1cm in front
of the junction of hard and soft palate and mediolater-
ally 0.5cm posterior to the midpalatine raphae to 2cm
in front of the palatal aspect of teeth 24 and 25. e sur-
face over the growth appeared verrucous and whitish in
appearance and the surrounding mucosa showed hyper-
melanotic areas. On palpation the growth was peduncu-
lated, non-tender, rm in consistency and arose from the
underlying soft tissue.
Case report 2
A 63-year-old male patient presented with a painless
growth in the right half of the tongue since 8 months.
Patient history revealed that the growth had been noticed
8 months prior to presentation which initially started as
a small growth and gradually increased over a period of
J. Stomat. Occ. Med. (2013) 6:106–109
DOI 10.1007/s12548-013-0079-6
Squamous papilloma
Report of two cases
B. Praveen Kumar, Tanya Khaitan, P. Ramaswamy, Sreenivasulu Pattipati,
S. Sudhakar, V. R. Geethika
S.Pattipati, MDS()·B. P.Kumar, MDS ·T.Khaitan, MDS ·
P.Ramaswamy, MDS · S.Sudhakar, MDS · V. R.Geethika, MDS
Department of Oral Medicine & Radiology,
St. Joseph Dental College & Hospital, Duggirala,
Eluru 534003, Andhra Pradesh, India
e-mail: dr.pattipati@gmail.com
Received: 5 February 2013 / Accepted: 2 March 2013 / Published online: 17 April 2013
© Springer-Verlag Wien 2013
Author's personal copy
case study
Squamous papilloma 107
4 months to attain the present size. e patient claimed
that there was no history of pain, paresthesia or numb-
ness and no similar lesions were present elsewhere.
e medical, dental, family and personal histories were
non-contributory.
Intraoral examination revealed the presence of a soli-
tary, well-dened, oval-shaped and exophytic growth
on the right anterior two thirds of the tongue measur-
ing approximately 1 × 0.8 cm in size (Fig.2). e growth
extended 0.5cm behind the tip of tongue and mediolat-
erally extended 0.5cm from the midline to 0.5 cm from
the right lateral border of the tongue. e surface over
the growth appeared pebbled and pale. On palpation the
growth was sessile, non-tender, rm in consistency and
arose from the underlying soft tissue.
Based on the history, clinical features and the nature
of the growth a provisional diagnosis of oral papilloma
was considered for the rst case report and irritational
broma for the second case report. Dierential diag-
noses of broepithelial polyp, broma and condyloma
acuminatum were considered. e patients were sub-
jected to complete hematological examination and all
the parameters were within normal limits. Both growths
were excised (Figs. 3 and 4) and specimens were sub-
jected to histopathological evaluation.
On microscopic examination the specimens showed
hyperparakeratinized stratied squamous epithelium
forming a number of blunt and pointed nger-like pro-
jections (Fig.5) with connective tissue cores continuous
with submucosal brovascular connective tissue with
scattered chronic inammatory cells. Koilocytes were
seen in the supercial (yellow arrow) and middle (red
arrow) spinous layers of the epithelium (Fig.6) sugges-
tive of squamous papilloma.
Fig. 1 Intraoral aspect showing a solitary, well defined, oval-
shaped and exophytic growth
Fig. 2 Intraoral view of the tongue showing a solitary, well-
defined, oval-shaped and exophytic growth
Fig. 3 Intraoral view in case 1 after the growth was excised
Fig. 4 Intraoral view in case 2 after the growth was excised
Author's personal copy
108 Squamous papilloma
case study
e patients were observed over a period of 3 and 6
months, respectively and no recurrence or new growth
was noted elsewhere.
Discussion
Oral squamous papilloma is a generic term that is used
to include papillary and verrucous growths consisting
of benign epithelium and minor amounts of supporting
connective tissue [6, 7]. It is the fourth most common oral
mucosal mass and is found in 4 out of every 1,000 lesions
[8]. Accounting for 3–4 % of all biopsied oral soft tissue
lesions this entity was rst reported as a gingival “wart”
by Tomes in 1848 and is a localized, benign HPV-induced
epithelial hyperplasia.
At least 150 dierent types of HPV have already been
identied, DNA sequences of HPV 16 and 18 have been
found in approximately 85 % of invasive squamous cell
carcinomas and precursors, such as grave dysplasia
and carcinoma in situ [1]. e infection starts when the
virus penetrates the new host through microinjuries. e
development of this incubation phase into active expres-
sion depends on three factors: cell permeability, virus
type and host immune status [2]. Infection by HPV acts as
an initiator and additional somatic mutations are essen-
tial, where the occurrence of these alterations is facili-
tated by smoking, other co-existent infections, dietary
deciencies and hormonal changes, all considered to be
co-factors in the pathogenesis [1].
e prevalence of HPV in normal oral mucosa (latent
infection) and its relation to oral cancer have generated
conicting opinions. e discrepancy observed is mainly
attributed to a variation in the sensitivity of the methods
employed and epidemiologic factors related to the group
of patients examined [2].
ere is no clearly dened mode of transmission
and most occur spontaneously [9]. eories have pro-
posed multiple pathways including perinatal transmis-
sion (during the passage through an infected birth canal
and in utero, as a transplacental or ascending infection),
autoinfection from orogenital contact by hand and sex-
ual transmission by orogenital contact [4].
Squamous papilloma occurs with equal frequency
in both men and women [10], can occur at any age and
are frequently seen in children and adolescents, usually
30–50 years of age. Intraorally, it is found most commonly
on the tongue, lips, buccal mucosa, gingiva and palate,
particularly areas adjacent to the uvula [8].
e lesions generally measure less than 1cm in the
largest dimension and appear as pink to white exophytic
granular or cauliower-like surface alterations [6, 7]. e
lesions are generally solitary in presentation although
several lesions have been noted on occasions. e lesions
are generally asymptomatic [6] and may be peduncu-
lated or sessile in conguration. Non-keratinized lesions
appear coral pink in color and if keratinized, they are
white. Some have a cauliower-like surface whereas oth-
ers have discrete nger-like projections [9]. Patients who
are HIV positive often have multiple oral lesions [7].
Clinically, the dierential diagnoses of broepithelial
polyp, broma and condyloma acuminatum were con-
sidered. Fibroepithelial polyp is a attened pink mass
that is attached to the palate by a narrow stalk. It is eas-
ily lifted up with a probe, which demonstrates its pedun-
culated nature [10]. Fibroma is a painless, broad-based
swelling that is paler in color than the surrounding tissue.
e surface may occasionally be traumatically ulcerated,
particularly in larger lesions. It is typically found in fre-
quently traumatized areas, such as the buccal mucosa,
lateral border of the tongue and lower lip [6]. Condy-
loma acuminatum is a sexually transmitted disease with
lesions developing at a site of sexual contact or trauma.
Oral lesions most frequently occur on the labial mucosa,
soft palate and lingual frenum. Clinically, it appears as
a sessile, pink, well demarcated, non-tender exophytic
mass with short, blunted surface projections [10].
Histopathologically, they are characterized by long,
thin, nger-like projections extending above the surface
Fig. 5 Histological section of the specimen from case XXX
showing hyperparakeratinized stratified squamous epitheli-
umforming a number of blunt and pointed fingerlike projections
Fig. 6 Koilocytes seen in the superficial (yellow arrow) and
middle (red arrow) spinous layers of the epithelium
Author's personal copy
case study
Squamous papilloma 109
of the mucosa, each made up of a continuous layer of
stratied squamous epithelium and containing a thin,
central connective tissue core which supports the nutri-
ent blood vessels [8]. e keratin layer is thickened in
lesions with a whiter clinical appearance and the epithe-
lium typically shows a normal maturation pattern. Occa-
sional papillomas demonstrate basilar hyperplasia and
mitotic activity which can be mistaken for mild epithe-
lial dysplasia [9]. Koilocytes (HPV altered epithelial cells
with perinuclear clear and nuclear pyknosis) may or may
not be found in the supercial layers of the epithelium
[7, 8].
More recently, gene therapy and vaccines targeted
against HPV are currently under trial whereby HPV
vaccines should eventually reduce the impact of these
viruses on human health [4]. At present two vaccines
have been developed: cervarix and gardasil provide pro-
tection against HPV types 6, 11, 16, 18 and both existing
vaccines are able to create a robust humoral immune
response which is much more eective than the levels of
antibodies that can be acquired after a general infection
[11].
Conservative surgical excision, including the base
of the lesion is the gold standard treatment for the oral
squamous papilloma and recurrence is unlikely. Fre-
quently, lesions have been left untreated for years with
no reported transformation into malignancy, continuous
enlargement or dissemination to other parts of the oral
cavity [10]. Papillomas are also treated by laser ablation
and the exophytic lesion is excised followed by direct
ablation of the lateral and deep margins [9]. Recently,
surgical excision combined with other forms of treat-
ment, such as systemically used interferon has been
introduced [12].
Conict of interest
e authors declare that there are no actual or potential
conicts of interest in relation to this article.
References
1. Carneiro TE, Marinho SA, Verli FD, Mesquita AT, Lima
NL, Miranda JL. Oral squamous papilloma: clinical, his-
tologic and immunohistochemical analyses. J Oral Sci.
2009;51(3):367–72.
2. Castro TP, Bussoloti Filho I. Prevalence of human papil-
lomavirus (HPV) in oral cavity and oropharynx. Rev Bras
Otorrinolaringol. 2006;72(2):272–82.
3. Syrjanen KJ, Pyrhonen S, Syrjanen SM. Evidence suggesting
human papillomavirus (HPV) etiology for the squamous
cell papilloma of the paranasal sinus. Arch Geschwulst-
forsch. 1983;53:77–82.
4. Campisi G, Giovannelli L. Controversies surrounding
human papilloma virus infection, head & neck vs oral can-
cer, implications for prophylaxis and treatment. Head Neck
Oncol. 2009:1(8).
5. Major T, Szarka K, Sziklai I, Gergely L, Czegledy J. e char-
acteristics of human papillomavirus DNA in head and neck
cancers and papillomas. J Clin Pathol. 2005;58:51–5.
6. Regezi JA, Scuibba JJ, Jordan RCK. Oral pathology: clinical
pathological correlations. 4th ed. St. Louis: Saunders; 2003.
pp.143, 61.
7. Jaju PP, Suvarna PV, Desai RS. Squamous papilloma: case
report and review of literature. Int J Oral Sci. 2010;2(4):222–5.
8. Rajendran R, Sivapathasundharam B. Shafer’s textbook of
oral pathology. 5th ed. Elsevier 2006. pp.113–5.
9. Silverman S, Eversole LR, Truelove EL. Essentials of oral
medicine. London; Decker; 2002. pp.146–7, 151.
10. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and
maxillofacial pathology. 2nd ed. Philadelphia: Saunders;
2002. pp.316–7, 441.
11. Mannarini L, Kratochvil V, Calabrese L, Gomez Silva L,
Morbini P, Betka J et al. Human papilloma virus (HPV) in
head and neck region: review of literature. Acta Otorhino-
laryngol Ital. 2009;29:119–26.
12. Sahin U, Tayyar S, Ercan D, Birol C, Selim C. Combination
of surgical excision and interferon alpha-2a treatment in
squamous cell papilloma with extensive oral involvement.
Dicle Med J. 2010;37(3):287–90.
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