ISSN 2231 – 2250
International Journal of Oral & Maxillofacial Pathology. 2011;2(4):59-62
Available online at http://www.journalgateway.com or www.ijomp.org
Case Report
Gingival Wart: An Uncommon Lesion
Deshingkar Sanket Abhaykumar, Barpande Suresh Ramchandra
Abstract
Warts are benign proliferations of skin and mucosa caused by the Human Papilloma Virus, a
group of double-stranded DNA viruses which can become completely integrated with the DNA of
the host cell. Intraoral warts are painless, exophytic growths usually white but sometimes pink,
solitary or multiple, sessile or pedunculated lesions displaying Verrucous, fingerlike projections.
The lesion is localized predominantly to palate, lip, buccal mucosa and tongue but rarely on the
gingiva. High prevalence of intraoral warts has been reported in HIV-positive patients and in other
immunocompromised conditions. Here a unique case of intraoral wart on gingiva is reported in
HIV-negative patient with its surgical management. Meticulous differential diagnosis should be
worked out before dealing with warty lesions in oral cavity.
Keywords: Papillomavirus Infections;Tumor Virus Infections;Warts;Verruca;Skin Diseases;HPV;
Papillomatosis;HIV-associated.
Deshingkar Sanket Abhaykumar, Barpande Suresh Ramchandra. Gingival Wart: An Uncommon Lesion.
International Journal of Oral & Maxillofacial Pathology; 2011:2(4):59-62. ©International Journal of Oral and
Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights
Reserved.
Received on: 30/04/2011
Accepted on: 03/08/2011
Introduction
Papillary
and
verruciform
epithelial
proliferations are quite common in the oral
and perioral region. These include
Squamous papilloma, Focal epithelial
hyperplasia,
Condyloma
accuminatum
(genital warts), Verruca vulgaris (common
wart), Verrucous leukoplakia, Verruciform
xanthoma, Verrucous carcinoma etc.1
Amongst these, the cases of oral wart are
not many but prevalence is mounting with
increase in pervasiveness of HIV-positive
patients.2-4 It is still rare to perceive the case
of gingival wart in immunocompetent
patient.1,4
Human Papilloma Virus (HPV) has been
implicated as a cause of oral wart and of
several other papillary and verruciform
epithelial proliferations.4 HPV is a group of
double-stranded DNA viruses which belongs
to family papovaviridae, subgroup A. HPV
can become completely integrated with the
DNA of the host cell and stimulate the rapid
proliferation of epithelial cells.4
Intraoral warts are solitary or multiple
exophytic, sessile or pedunculated lesions
displaying verrucous or papillomatous
projections. Clinically it appears as a soft
lesion usually white in color but sometimes
may also be pink. Intraorally it is found most
commonly on the palate followed by lip,
tongue, buccal mucosa and rarely seen on
the gingiva.2 The term “Gingival wart” was
first coined by Tomes in 1848 and described
it as a localized, benign, Human Papilloma
Virus (HPV)-induced epithelial hyperplasia
on gingiva.1 Intraoral warts can occur at any
age but are most commonly seen in age
group of 30-50 years with equal incidence in
both genders.3 Usually the lesion is
asymptomatic, but may cause cosmetic
problems when present on lips.4 Infectivity
rate of oral wart is extremely low.
Case History
A 27-year-old male patient reported in
Department of Oral Pathology, Government
Dental College and Hospital, Aurangabad,
with complaint of painless, papillary growth
on the right maxillary buccal gingiva
adjacent to 15. The growth was present
since last two years which gradually
increased in size. Since last six months
there was no significant change in the size
of growth. Intraoral examination revealed a
solitary, well circumscribed, whitish growth
of size 0.6 x 0.6 cm (Fig 1a). The growth
was sessile with verrucous projections on
the surface and was firm in consistency. The
lesion extended from distal of 14 to mesial of
16 and involved the marginal and attached
gingiva of 15. No history of similar lesions on
skin and genital area. Blanching and fibrous
bands were present on right and left
The purpose of this report is to present the
unusual case of gingival wart along with its
differential diagnosis and to supplement the
existing clinical knowledge about this rare
entity.
©2011 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved
60
Deshingkar Sanket et al
posterior buccal mucosa and retromolar
area with restricted mouth opening.
Intra-oral periapical (IOPA) radiograph of
lesional area did not show any hard tissue
abnormality and blood examination findings
were within normal limits. Hepatitis-B and
HIV infections were ruled out by ELISA.
Patient was maintaining his oral hygiene
with toothbrush and toothpaste twice a day.
He had a habit of chewing tobacco and
gutkha (5 to 6 times per day) for 6 to 7
years, but had left both the habits since 5 to
6 months. There was no history of any
trauma to lesional area. The growth was
surgically excised including base of growth
with 1mm of surrounding normal gingiva (Fig
1b & c).
Histopathologic examination of Hematoxylin
and Eosin (H & E) stained sections showed
exophytic growth covered by proliferated
keratinized stratified squamous epithelium
with moderately elongated rete ridges
tending to converge toward the centre of
lesion, producing “cupping” effect. Some of
the cells in superficial layer of epithelium
showed
appearance
resembling
to
koilocytes (HPV-altered epithelial cells with
perinuclear clear spaces and nuclear
pyknosis). No features of epithelial dysplasia
were seen. The underlying connective tissue
showed diffusely distributed moderate
amount of chronic inflammatory cell infiltrate
(Fig 2a & b). The histopathology was
suggestive of “verrucous hyperplasia”. On
the basis of clinico-pathologic correlation,
the final diagnosis of “oral wart on the
maxillary gingiva” was rendered. Due to
unavailability of resources, detection of HPV
by screening probes could not be done. The
patient was on regular follow-up for two
months after surgery and no sign of
recurrence was noted.
Discussion
Papillary and verruciform proliferations are
quite common exophytic lesions in the oral
cavity, representing at least 3 to 4% of all
biopsied oral lesions.1 Though the exact
etiology is unknown, the intraoral warts are
thought to be induced by viral infection of
epithelium, especially by HPV (HPV2,6,7,11,13,16,18,31,33,35,55,59 and 69).2,4
Various possible risk factors for oral HPV
lesions are immune-compromised conditions
like HIV infection and renal transplantation,
patients with current or previous infection
with hepatitis-B virus and AIDS patients
undergoing highly active anti-retroviral
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therapy (HAART) regimen.4 However, in the
present case the patient did not have any of
the above mentioned diseases. Bouquot JE
(1986) reported relatively low prevalence
(<0.5%)
of
intraoral
warts
in
immunocompetent host.5 However, a high
prevalence of oral wart has been reported in
persons who had undergone renal transplant
by King GN et al. (1994) and later in HIVpositive patients by King DM et al. (2002).4
Intraoral warts should be differentiated from
other papillary and verruciform lesions in the
oral cavity. These include squamous
papilloma, condyloma accuminatum, focal
epithelial hyperplasia, fungiform papilloma,
verruciform
xanthoma,
proliferative
verrucous leukoplakia (PVL) and verrucous
carcinoma.5 The clinical and histological
differentiating features are summarized in
Table 1.
In the present case report, morphologically,
the lesion showed papillomatous growth. It
clinically resembles to the wart showing
solitary, sessile, painless growth which was
white in color and present on the maxillary
buccal gingiva since two years without much
change in size and morphology. No similar
lesions were found elsewhere in the oral
cavity and on any other site of body.
Histopathologic
picture
revealed
an
exophytic
growth
with
covering
of
proliferated keratinized stratified squamous
epithelium without dysplasia. It was
suggestive of verrucous hyperplasia.
Considering the clinical presentation and
histopathology, final diagnosis of “oral wart
on maxillary gingiva” was made.
The possibility of condyloma accuminatum
(genital wart) and fungiform papilloma was
ruled out as they are found more commonly
on genital area and sino-nasal tract
respectively.6,7 Absence of multiple lesions
rules out the possibility of contagiousness
and subsequently possibility of condyloma
accuminatum, focal epithelial hyperplasia.3,7
Also, absence of multiple lesions with skin
involvement and lack of contagiousness
advocates that this lesion did not resemble
to verruca vulgaris (common wart).1,3 The
histopathologic picture in present case did
not show long, thin, finger-like projections
extending above the surface of mucosa,
each containing a thin central connective
tissue core which supports the nutrient
vessels, ruling out the diagnosis of
squamous papilloma.6
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Gingival Wart: An Uncommon..... 61
Figure 1: a) A well circumscribed, sessile, whitish, papillary growth on the buccal gingiva. b)
Complete surgical excision of growth. c) Excised specimen showing margin of normal gingiva.
Figure 2: The photomicrograph under low power view (a) demonstrates verruciform epithelium
with elongated rete ridges tend to converge toward center of the lesion producing “cupping” effect
and inflammation in the underlying connective tissue and under high power view shows
vacuolated epithelial cells (koilocytes) in the superficial layer (b).
Squamous
papilloma
Focal epithelial
hyperplasia
(Heck’s disease)
Fungiform
papilloma
Verruca vulgaris
(Common wart)
Condyloma
accuminatum
(Genital wart)
Verruciform
xanthoma
Proliferative
verrucous
leukoplakia
Verrucous
carcinoma
- Clinically similar to intraoral wart
- Consists of many long, thin, finger-like projections extending above the surface of
the mucosa, each made up of stratified squamous epithelium and containing a thin
central connective tissue core which supports the nutrient blood vessels.
- Contagious lesion, always multiple and sessile.
- Extreme hyperplasia of prickle cell layer of epithelium with minimal production of
surface projection.
- Bears similarities with intraoral wart.
- Most frequently occurs in sino-nasal tract.
- More aggressive biologic nature.
- Commonly involving skin and produces multiple verrucous lesions.
- Highly contagious and infective, spread by autoinoculation.
- Histologically, elongated rete ridges which tend to converge toward the center of
lesion, producing a “cupping” effect.
- Abundant koilocytes (HPV altered epithelial cells with perinuclear clear space and
nuclear pyknosis) in the superficial spinous layer.
- More common at the site of sexual contact or trauma.
- Usually multiple and sessile.
- Very contagious and spread by autoinoculation.
- Hyperplastic condition of epithelium of mouth, skin and genitalia.
- Lipid laden histiocytes beneath the epithelium.
- Premalignant lesion showing multiple keratotic plaques with roughened surface
projection and may become invasive without change in clinical appearance.
- Mostly occurs in older women.
- Warty variant of squamous cell carcinoma.
- Exophytic overgrowth of keratinizing epithelium having minimal atypia and with
locally destructive pushing margins at its interface with underlying connective tissue.
- Parakeratin plugging with epithelial dysplasia on histologic examination is hallmark.
Table 1: Differential diagnosis of oral papillary and verruciform lesions
62
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Deshingkar Sanket et al
Focal epithelial hyperplasia and verruciform
xanthoma were ruled out by absence of
extreme hyperplasia of prickle cell layer of
epithelium and accumulation of lipid laden
histiocytes
beneath
the
epithelium,
respectively.3,7 The diagnosis of PVL was
excluded by the absence of multiple
keratotic plaques with roughened surface
projections and epithelial dysplasia.3,8
Histopathologic picture of the present case
was suggestive of verrucous hyperplasia
that may resemble to verrucous carcinoma
with minimal epithelial atypia.8 In the former,
the verrucous processes and the greater
part of the hyperplastic epithelium are
superficial to adjacent normal epithelium.
Whereas in verrucous carcinoma even
though the verrucous processes are
superficial, the broad rete ridges extend
considerably deeper than adjacent normal
epithelium, often pulling a margin of normal
epithelium along with them into the
underlying connective tissue.9
Regarding treatment of papillary and
verrucous lesions, various modalities other
than surgery includes liquid nitrogen
cryotherapy, laser vaporization and topical
application of keratinolytic agents (usually
salicylic acid and lactic acid).1 Frequently
similar lesions have been left untreated for
years
together
with
no
reported
transformation
into
malignancy
or
continuous enlargement or dissemination to
other parts of oral cavity.1
Conclusion
Although the warts are uncommon in oral
cavity and especially rare on gingiva yet
considering the clinical presentation and
histopathologic examination, diagnosis of
“oral wart on maxillary gingiva” was made.
Various papillary lesions in the oral cavity
can produce similar clinical picture. Hence, it
becomes extremely important for dentist to
be
familiar
with
the
clinical
and
histopathologic characteristics of various
oral papillary and verruciform lesions in
order to be able to give a reasonably specific
diagnosis and adequate treatment.
Author affiliations
1. Dr. Deshingkar Sanket Abhaykumar, Assistant
Professor, 2. Dr. Barpande Suresh Ramchandra,
Dean, Professor and Head, Department of Oral
Pathology and Microbiology. Government Dental
College and Hospital, Aurangabad – 431 001,
Maharashtra, India.
Acknowledgement
We would like to thank all the staff members in
the Department of Oral and Maxillofacial
Pathology for their cooperation and support.
References
1. Bond TE. Bond’s book of oral disease.
Squamous papilloma, fourth edition
[Internet]. United states, 1999 [cited
2011
April
28].
Available
from
http://www.maxillofacialcenter.com/Bond
Book/mucosa/papilloma.html
2. Terai M, Takagi M, Matsukura T, Sata T.
Oral wart associated with Human
Papilloma Virus Type 2. J Oral Pathol
Med 1999;28(3):137-40.
3. Neville BW, Damm DD, Allen CM,
Bonquot JE. Editors. Oral and
Maxillofacial Pathology. 3rd ed. New
Delhi: Reed Elsevier India Pvt. Ltd.;
2009. 362p.
4. King MD, Reznik DA, Christine MD,
Mark D, Larsen NM, Osterholt D, et al.
Human Papilloma Virus associated oral
warts among Human Immunodeficiency
Virus seropositive patients in the era of
highly active anti-retroviral therapy: an
emerging infection. Clin Infect Dis
2002;34:641-8.
5. Bouquot JE. Common oral lesions found
during a mass screening examination. J
Am Dent Assoc 1986;112(1):50-7.
6. Shafer WG, Hine MK, Levy BM, Tomich
CE. Editors. A Textbook of Oral
Pathology. 4th ed. Philadelphia: W B
Saunders; 1983. 86-229p.
7. Bouquot JE, Wrobleski GJ. Papillary
(pebbled) masses of the oral mucosa:
more than simple papilloma. Prac Perio
Aesthetic Dent 1996;8:533-43.
8. Rajendran R. Benign and malignant
tumors of the oral cavity. Rajendran R.,
Sivpathasundhram B. Editors, Shafer’s
Textbook of Oral Pathology. 6th ed. New
Delhi: Reed Elsevier India Pvt. Ltd.;
2006. 80-218p.
9. Shear M, Pindborg JJ. Verrucous
hyperplasia of oral the mucosa. Cancer
1980;46(8):1855-62.
Corresponding Author
Dr. Deshingkar Sanket Abhaykumar
Assistant Professor,
Department
of
Oral
Pathology
and
Microbiology,
Government Dental College and Hospital,
Aurangabad – 431 001, Maharashtra, India.
Mobile: 09762980179 / 09096904269
E-mail: [email protected]
Source of Support: Nil, Conflict of Interest: None Declared.