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CASE REPORT
Year : 2018  |  Volume : 21  |  Issue : 12  |  Page : 1674-1677

Recurrent oral squamous papilloma in a pediatric patient: Case report and review of the literature


1 Department of Child Dental Health, Faculty of Dental Sciences, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Child Dental Health, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Oral and Maxillofacial Pathology/Biology, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Acceptance28-Feb-2018
Date of Web Publication18-Dec-2018

Correspondence Address:
Dr. A B Olawuyi
Department of Oral and Maxillofacial Pathology/Biology, Lagos University Teaching Hospital, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_407_17

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   Abstract 


Squamous papillomas are common lesions of the oral mucosa. They are benign proliferating lesions often painless, slow growing and with a cauliflower appearance. However, its clinical appearance which sometimes mimics exophytic carcinoma, verrucous carcinoma or condyloma acuminatum raises concern when it occurs in the oral cavity. Squamous papilloma occurs predominantly in 30- to 50-year old's. However, they may be seen in children <10 years and accounted for 8% of all oral tumors in children. There is no sex predilection. It has a predilection for the tongue and soft palate, but may occur on any other surface of the oral cavity. Oral squamous papillomas have been associated with infection by the human papilloma virus (HPV). The present report is a case of a recurrent squamous papilloma of the hard palate in a 5-year-old patient with a review of the literature.

Keywords: HPV,oral cavity, pediatric, squamous papilloma


How to cite this article:
Orenuga O O, Oluwo, Oluwakuyide R T, Olawuyi A B. Recurrent oral squamous papilloma in a pediatric patient: Case report and review of the literature. Niger J Clin Pract 2018;21:1674-7

How to cite this URL:
Orenuga O O, Oluwo, Oluwakuyide R T, Olawuyi A B. Recurrent oral squamous papilloma in a pediatric patient: Case report and review of the literature. Niger J Clin Pract [serial online] 2018 [cited 2019 Oct 23];21:1674-7. Available from: http://www.njcponline.com/text.asp?2018/21/12/1674/247685




   Introduction Top


Oral squamous papillomas are common lesions of the oral mucosa of squamous epithelial origin presenting as a papillary or verrucous exophytic mass.[1] It is the 4th most common benign epithelial lesion associated with human papilloma virus (HPV) types 6 and 11.[2] The most common site of occurrence is the tongue and soft palate, however, other sites in the oral cavity may be affected.[1],[2]

The etiology of oral squamous papilloma is unknown but it has been associated with HPV 6, 11 and trauma. HPV has been found to have the ability to invade the nuclei of cells in the spinous layer resulting in proliferative tissue growth.[3] A recent report in the scientific literature, however, suggests that presence of HPV may be merely an incidental finding unrelated to the development of a squamous papilloma.

Mode of transmission for children has been reported as ingestion of viral particles of infected cells from the birth canal, whereas in adults through sexual contact.[1]

Oral squamous papilloma may present as a more sinister lesion mimicking lesions like exophytic carcinoma, verrucous carcinoma or condyloma acuminatum.[4]

Diagnostic techniques in the detection of HPV are based on the morphological effects of the virus on tissue, also on the presence of HPV DNA, which can be detected using the polymerase chain reaction (PCR).[5]

There is a very limited literature on squamous papilloma of the oral cavity in children from Nigeria and sub-Saharan Africa. We therefore report this case in a child to increase the body of knowledge available on this subject in our environment.


   Case Summary Top


A 5-year-old female patient reported to the Pediatric Dentistry Outpatient Clinic of the Lagos University Teaching Hospital in February 2015, with the chief complaint of a growth on the anterior palate of 3 months duration. Growth started as a small nodule that has gradually increased in size to its present size, she also complained of pain while eating. There was no history of paresthesia or numbness associated with the growth and no similar lesions were present elsewhere. Family history was not significant. There was no medical or dental history of significance.

Clinical examination revealed a warty pedunculated growth on the anterior hard palate of size around 10 × 7 mm. Swelling was pink in color, firm in consistency and did not interfere with the occlusion. A provisional diagnosis of oral squamous papilloma was made. A complete surgical excision up to 1 mm margin to the depth of the submucosa and a small area of surrounding normal tissue was done and specimen was submitted for histopathologic analysis [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Photomicrograph showing the initial lesion before and after excision

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Histopathologic reports showed hyperkeratinized stratified squamous epithelium with thin fibrovascular connective tissue core. The connective tissue contained small endothelial lined vascular channels and a few chronic inflammatory cells consisting mostly of lymphocytes. Koilocytic cells were also seen [Figure 2].
Figure 2: Photomicrograph showing the initial lesion showing hyperkeratinized stratified squamous epithelium with thin fibrovascular connective tissue core (H and E, ×10)

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These findings are consistent with the strict histopathologic criteria for the diagnosis of oral squamous papilloma suggested by Carneiro et al.[4]

In February 2017, patient presented with a recurrence of the lesion on the palate at a site distal to the initial lesions, and was about 6 × 5 mm in size and was excised [Figure 3]a and [Figure 3]b. Histopathologic examination revealed hyperplastic parakeratotic stratified squamous epithelium thrown into papillomatous projections. A few virally modified cells suggestive of koilocytes were seen in the epithelium. Within the connective tissue were seen endothelial lined vascular channels and sprinkles of chronic inflammatory cells infiltrate [Figure 4].
Figure 3: (a and b) Photomicrograph showing the recurrent lesion before and after excision

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Figure 4: Photomicrograph stratified squamous epithelium thrown in to papillomatous projections with a central connective tissue core

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   Discussion Top


Squamous papilloma presents a pedunculated lesion with cauliflower-like surface. They present as single multiple or diffusely involving broad areas of the oral mucosa. In this case it presented as a single cauliflower-like lesion as reported by Abbey et al.[5]

Oral squamous cell papilloma has been reported to be the most common oral tumor. In 2000, Rafindadi et al.[6] reported oral squamous cell papilloma as the most commonly seen oral tumors in Nigeria, Al-Khateeb et al.[7] also reported the same.

Oral squamous cell papilloma is more common in the palate.[1],[8] This is what we also found in our patient. However, Major et al.[9] reported the labial mucosa as the most common site, while Flint et al.[10] reported the tongue. Das and Das[11] and Abbey et al.[5] have reported these lesions in the uvula, tongue, lips and gingiva.

Although the exact etiology of squamous papilloma is unknown,[8] it is believed to be related to HPV especially HPV 6 and 11. However, trauma has also been implicated in the etiology of papilloma.[8] HPV is said to have the capability to invade the nuclei of the cells in the spinous layer thereby inducing a series of proliferative alterations resulting in growth.[3]

Etiology of HPV in children is controversial, however, various mechanisms have been proposed. In children younger than 1 year of age with papilloma lesions, maternal–fetal or maternal–neonatal HPV transmission has been implicated. It may also result from hematogenous spread from a recent infection or reactivation of a latent infection in the mother.[3],[12],[13]

In older children, transmission may be attributed to either auto (autoinoculation by hand to genital area and genital area to hand or mouth, non-sexual contact or perinatal transmission) or heteroinnoculation.[13] However, Yoshpe[13] reported the possibility of sexual abuse as a mode of transmission when other routes have been ruled out. Puranen et al.[14] also proposed horizontal transmission through saliva or other contacts for children whose mothers are HPV negative. However, we could not ascertain the exact mode of transmission in our case, even though we queried sexual abuse in our patient because of the recurrence, there was no evidence to back it up.

Diagnosis involves various techniques such as cytology, biopsy, immunohistochemistry and molecular techniques.[2],[3] As it can be challenging because of its clinical similarities to other epithelial lesions, like condyloma acuminatum and verruca vulgaris. In our case, the diagnostic method we used was biopsy. Although we also wanted to use the PCR techniques, but lack of adequate facilities prevented us.

Carneiro et al.[4] in their own study, gave some strict histopathologic criteria for the diagnosis of oral squamous papilloma. The strict histopathologic criteria were as follows: squamous epithelium arrayed in finger-like projections, normal maturation pattern and presence of hyperparakeratosis in the epithelium, koilocytosis as a result of perinuclear cytoplasmic vacuolization of cells of the spinous layer of the epithelium, producing perinuclear pale/clear halos and pyknosis and the occasional presence of basilar hyperplasia. Our histopathologic findings fulfill these criteria. Surgical removal is the treatment of choice by either routine excision or laser ablation. Other treatment modalities include electrocautery, cryosurgery and intralesional injections of interferon.[13]

Oral squamous papilloma are common oral lesions, even though they are rarely seen in children. They have a predilection for the tongue and palate and are associated with infection by HPV 6 and 11 variants. We suspected sexual abuse in the present case, but our investigations did not confirm such. Surgery, electrocautery and cryosurgery are treatment options.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Naik S, Nidoni M. Oral squamous papilloma of the palate – A case report. Int J Dent Sci Res 2014;6B: 17-8.  Back to cited text no. 1
    
2.
Bond TE. Bond's book of oral disease. Squamous papilloma. 4th ed. 1999. Available from: http://www.maxillofacialcenter.com/ BondBook/mucosa/papilloma.html. [Last accessed on 2017 Apr 06].  Back to cited text no. 2
    
3.
Syrjänen S, Puranen M. Human papillomavirus infections in children: The potential role of maternal transmission. Crit Rev Oral Biol Med 2000;11:259-74.  Back to cited text no. 3
    
4.
Carneiro TE, Marinho SA, Verli FD, Mesquita AT, Lima NL, Miranda JL. Oral squamous papilloma: Clinical, histologic and immunohistochemical analyses. J Oral Sci 2009;51:367-72.  Back to cited text no. 4
    
5.
Abbey LM, Page DG, Sawyer DR. The clinical and histopathologic features of a series of 464 oral squamous cell papillomas. Oral Surg Oral Med Oral Pathol 1980;49:419-28.  Back to cited text no. 5
    
6.
Rafindadi AH, Ayuba GI. Oral tumours in Zaria. Nigerian J Surg Res 2004;2:21-5.  Back to cited text no. 6
    
7.
Al-Khateeb T, Al-Hadi Hamasha A, Almasri NM. Oral and maxillofacial tumours in North Jordanian children and adolescents: A retrospective analysis over 10 years. Int J Oral Maxillofac Surg 2003;32:78-83.  Back to cited text no. 7
    
8.
Wanderley F, de Paula e Silva G, de Queiroz AM. Oral papilloma in pediatric patients. Braz J Oral Sci 2006;5:938-40.  Back to cited text no. 8
    
9.
Major T, Szarka K, Sziklai I, Gergely L, Czeglédy J. The characteristics of human papillomavirus DNA in head and neck cancers and papillomas. J Clin Pathol 2005;58:51-5.  Back to cited text no. 9
    
10.
Richardson M, Flint P, Haughey B, Lund V, Niparko J, Robbins K, et al. Benign neoplasms. In: Cummings Otolaryngology – Head and Neck Surgery. 5th ed. Philadelphia, Pa, USA: Elsevier Mosby; 2010  Back to cited text no. 10
    
11.
Das S, Das AK. A review of pediatric oral biopsies from a surgical pathology service in a dental school. Pediatr Dent 1993;15:208-11.  Back to cited text no. 11
    
12.
Wang X, Zhu Q, Rao H. Maternal-fetal transmission of human papillomavirus. Chin Med J (Engl) 1998;111:726-7.  Back to cited text no. 12
    
13.
Yoshpe NS. Oral and laryngeal papilloma: A pediatric manifestation of sexually transmitted disease? Int J Pediatr Otorhinolaryngol 1995;31:77-83.  Back to cited text no. 13
    
14.
Puranen MH, Yliskoski MH, Saarikoski SV, Syrjänen KJ, Syrjänen SM. Exposure of an infant to cervical human papillomavirus infection of the mother is common. Am J Obstet Gynecol 1997;176:1039-45.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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