Multifocal Gingival Squamous Cell Papilloma: A Case Report and Literature Review
Correspondence Address :
Dr. Shikha Tewari,
Senior Professor, Department of Periodontics, Post Graduate Institute of Dental Sciences, Rohtak-124001, Haryana, India.
E-mail: drshikhatewari@yahoo.com
Squamous Cell Papilloma (SCP) is a benign, asymptomatic, exophytic cauliflower-like growth of mucosal mass. It is mostly associated with Human Papilloma Virus (HPV) subtypes 6 and 11, and has a very low virulence and infectivity rate. The papillomas are commonly known as warts or verrucas when found on the skin. The typical lesion is a single mass with finger-like extensions, resembling a soft, pedunculated growth supported by a stem or stalk. If keratin, a skin protein, accumulates around the lesion, the projections can be long and pointed or short and rounded. Intraorally, the most common sites of occurrence are the tongue, lips, buccal mucosa, palate, and uvula. Hereby, the author present a case report of 25-year-old male patient with a 4×9 mm exophytic growth exhibiting a pebbled surface in the upper left first premolar region, with no signs of radiographic bone loss. Additionally, smaller pinpoint lesions were observed bilaterally in the interdental region of the first and second maxillary molars. A nevus on the right side of the face was also noted. Histological analysis confirmed the diagnosis of SCP. The presence of multifocal gingival squamous papilloma, along with an extraoral nevus, represents a novel finding that warrants reporting. The gingival lesion in the maxillary left first premolar region was surgically excised, along with 1 mm of healthy surrounding gingiva. This resulted in complete healing, and no recurrence was observed during the 12-month follow-up period.
Benign neoplasm, Human papilloma virus, Oral cavity
A 25-year-old male patient reported mild intermittent pain and irritation in the gums while chewing hard food in the upper left-side region for the past six months. The dental and medical history were non contributory. Intraoral clinical examination revealed a pinkish, exophytic sessile growth measuring 4×9 mm with a pebbled surface on the facial marginal and attached gingiva in the maxillary left first premolar region. The lesion did not involve the mucogingival junction. The surrounding gingiva appeared normal, with no bleeding on probing and a pocket depth of 3 mm around the same tooth. Similar solitary pinpoint lesions were observed bilaterally in the interdental papillary region of the first and second maxillary molars (Table/Fig 1)a-d. Extraorally, a hard and sessile nevus measuring 8×9 mm was present on the right side of the face, lateral to the nostril. The nevus was non-painful and had been present since birth, as reported by the patient (Table/Fig 1)e.
No intervention was performed for the extraoral nevus at this point. The patient was advised and referred to a surgeon for an opinion. However, the patient expressed disinterest in seeking treatment for the nevus. Regarding the gingival lesions, no radiographic bone loss was evident in relation to the maxillary left first premolar or the interdental area between the first and second maxillary molars on either side (Table/Fig 2)a-c.
A provisional diagnosis of gingival squamous papilloma was made, with differential diagnoses including papillary hyperplasia, verruciform xanthoma, condyloma acuminatum, and verruca vulgaris. Excisional biopsy was planned for the exophytic tissue present on the mid-buccal surface of the maxillary left first premolar, while the pinpoint lesions were left untreated. The patient provided written informed consent after the procedure was explained. Complete haemogram levels were within normal limits, and full mouth scaling and root planing were performed. The biopsy was conducted in accordance with the ethical standards outlined in the 1975 Declaration of Helsinki, as revised in 2013. Under local anaesthesia, the lesion was excised along with 1 mm of surrounding healthy gingiva (Table/Fig 3)a-c using a No.15 Bard Parker (BP) blade, and periodontal dressing* was applied to the site. The excised tissue was sent for histopathological {Haematoxylin and Eosin (H&E)}.
Histological features included hyperkeratinised stratified squamous epithelium projecting as finger-like papillary projections with fibrovascular cores. Some fibrovascular cores showed hyalinised stroma. The underlying stroma exhibited small and large vascular channels and a moderate amount of inflammatory cell infiltrate, predominantly lymphocytes. Additionally, koilocytes were also observed (Table/Fig 4)a-c. These findings confirmed the diagnosis of gingival SCP.
Following the surgery, the patient was recalled after one week for evaluation, and the healing process was uneventful. Follow-up examinations at 1, 6, and 12 months showed no signs of recurrence (Table/Fig 5)a,b.
Squamous Cell Papilloma (SCP) is a benign exophytic growth characterised by localised verrucous or cauliflower-like proliferation. The aetiology of SCP includes mechanical and chemical irritation and/or infection with HPV subtypes 6, 11, and 16, with HPV 6 and 1311 having low oncogenic potential (1). SCP is the fourth most common oral mucosal lesion, accounting for 4 in 1000 of all biopsied lesions (2). It often occurs in the age group between 30-50 years with a higher predilection in males. HPV lesions are infectious, but SCPs have an extremely low virulence and infectivity rate (1).
Squamous Cell Papillomas (SCP) most commonly occurs on the vermillion of the lips, hard and soft palate, with a high predilection for the uvula (3). However, its occurrence on the gingiva is relatively rare (3),(4). This case report presents a case of multifocal gingival squamous papillomas, with a lesion on the keratinised mid-buccal gingiva in relation to the upper left first premolar, smaller pinpoint lesions bilaterally in the interdental region of the first and second maxillary molars, and a nevus on the right side of the face lateral to the nostrils. Basal cells of the gingival epithelium are considered one of the possible reservoirs of latent HPV infection (5). The aetiopathogenesis of squamous papilloma of the gingiva could be explained by the presence of local irritation or persistent inflammation of the gingiva, leading to increased epithelial cell division, which further aids in HPV replication (5).
The current case presents a squamous papilloma involving the marginal and attached gingiva of the maxillary left first premolar. Although no radiographic bone loss was evident. Histopathologically, SCPs present as characteristic finger-like projections showing hyperkeratosis, with a fibrovascular core and a hyalinised stroma containing a marked granular cell layer. Koilocytes may or may not be seen. Under conditions of chronic irritation or trauma, small foci of lymphocytes can be observed at the base of the lesion (3). In the present case report, the patient complained of gum irritation during mastication, and clinical findings revealed multifocal exophytic gingival lesions along with a nevus on the face. Furthermore, histological findings demonstrated typical features of SCP, along with the presence of lymphocytes and koilocytes. All these findings pointed towards a viral aetiology. Differential diagnoses of squamous papilloma may include papillary hyperplasia, verruciform xanthoma, condyloma acuminatum, and verruca vulgaris (6). The limitation of the present case report includes the absence of advanced techniques such as Polymerase Chain Reaction (PCR), comet assay, and DNA Break Detection/Fluorescence in-situ Hybridisation (DBD-FISH) testing to confirm HPV involvement. Treatment of squamous papilloma includes surgical excision in toto, including the base of the lesion and a small area of marginal tissue. Laser treatment has also been proposed as an alternative treatment option to surgical scalpel in the literature (7). Recurrence of SCP is relatively rare, except for Human Immunodeficiency Virus (HIV) infected lesions (8).
Literature review: In a review of the literature a case report showed the presence of a cauliflower-like growth 6x10 mm with tiny finger-like projections on the facial aspect of the mandibular left second premolar, involving the keratinised gingiva with mild crestal bone loss (Table/Fig 6) (1),(4),(9),(10),(11),(12),(13),(14),(15).
The lesion present in the maxillary left first premolar region was surgically excised along with 1 mm of healthy surrounding gingiva, resulting in a complete healing. No signs of recurrence were observed during the 12-month follow-up period.
DOI: 10.7860/JCDR/2023/64086.18337
Date of Submission: Mar 18, 2023
Date of Peer Review: Apr 24, 2023
Date of Acceptance: May 23, 2023
Date of Publishing: Aug 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 23, 2023
• Manual Googling: Apr 19, 2023
• iThenticate Software: May 17, 2023 (10%)
ETYMOLOGY: Author Origin
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