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Oral condyloma acuminatum
Section
of the
Federal dental services
Oral condyloma acuminatum Milton J. Knapp, Lieutenant Colonel, DC, USA,* and George I. Uohara, Lieutenant Colonel, DC, USA”” UNITED
STATES
ARMY
ARMOR
CENTER,
FORT
KNOX,
KY.
W
arts are virus-induced epithelial growths of the integument and mucous membranes. Generally, they are separated into four clinical varieties: (l)verruca vulgaris, the papillary wart found commonly on the hands of the young and less commonly on the lips and oral mucous membranes ; (2) verruca plana, the flat or plane wart most commonly affecting the face and dorsa of the hands in childhood; (3) verruca plantaris, the hyperkeratotic excrescences frequently occurring at pressure sites ; and (4) condyloma acuminatum, the warty growths which occur in the warm, moist, intertriginous areas about the genitals or anus.l-” The occurrence of verruca vulgaris in the oral cavity is well established. Of the remaining types of verruca it appears reasonable that condyloma acuminatum would occur on the oral mucosa with a relative degree of frequency. Verruca vulgaris and condyloma acuminatum are similar in origin ; they occur on the skin and mucous membra,nes; some spontaneous regression may be seen in each; and both are transmissible and auto-inoculable.5 HOWever, a review of the literature reveals no reported incidence of condyloma acuminatum of the oral mucous membranes. Condyloma acuminatum is a papillomatous growth which occurs most frequently on anogenital skin and mucosa but may also involve other warm, moist, intertriginous areas. These lesions may appear singly or as soft, pink, papillomatous clusters of varying sizes and proportion@ (Fig. 1). Condylomas generally respond readily to treatment wit,h podophyllin, but there is a tendency toward multiple local recurrences.7 The opinions or assertions contained in this article are the private ones of the writers and are not to be construed as official or reflecting the views of the Department of the Army or the Defense Department at large. *Chief, Oral Pathology, Dental Detachment. **Chief, Periodontics, Dental Detachment.
538
Volume Number
0ra.l condyloma acumhatum
23 4
Pig. 2. Papillomatous
clusters
539
on penis.
CASE REPORT An 1%year-old well-nourished, well-developed Caucasian soldier reported to the dental clinic for examination with the chief complaint of “enlarged gums” of many years’ duration. Extraoral examination findings and the family history were unremarkable. Physical examination revealed a well-developed, slender, well-oriented Caucasian male in no apparent distress. The patient was under no medical treatment and was taking no medication. Fxamination of the skin, including the anogenital area, was entirely negative. The results of all laboratory tests, including a complete blood count, urinalysis, and serologic and bacteriologic studies were within normal limits. The remainder of the examination was noncontributory. Laboratory tests were repeated, with negative results. Intraoral examination revealed extremely poor oral hygiene, with multiple caries and heavy deposition of calculus. The maxillary gingiva presented a firm, verrucous enlargement of the gingival tissues, extending from the midline to the mesial aspect of the upper left second premolar, encroaching in the in&al area to the mucogingival junction (Fig. 2). Palatally, the lesion extended to the same limits, with pronounced involvement of the lateral incisor and cuspid areas (Fig. 3). Involvement of the mandibular gingiva extended from the mesial aspect of the left first molar to the medial aspect of the right second premolar. The entire attached gingiva in this area was involved, and the convexity of its bulbous configuration overlapped beyond the mucogingival junction (Fig. 4). Intraoral roentgenograms and examinations revealed periodontitis with minor bone loss. In addition, satellite lesions extended into the areas of the buccinator frenula bilaterally (Figs. 5 and 6). In the lower lingual aspect, the verrucous growth extended to areas corresponding to the labial involvement (Fig. 7). Clinically, the entire lesion exhibited various degrees of chronic inflammation. The interdental papilla of the upper right incisor area revealed minimal involvement (Fig. 6). Other oral soft tissues and the oropharynx were not involved. Periodontal surgical treatment was accomplished in two visits. At the first visit the entire maxillary involved gingiva, including part of the periosteum, was removed (Figs. 8 and 9). The surgical area was carefully curetted, scaled, irrigated, and dressed with surgical pack. A similar procedure was performed on the mandibular gingiva and mucosa ((Figs. 10 and 11). Healing was rapid and uneventful. Subsequent to the surgical procedure, the patient was transferred to another station. An 8 month follow-up report indicated that the lesion on the lower lingual gingiva had recurred, extending onto the mucosa of the floor of the mouth.8 Pathology
report
Gross. Two specimens were submitted. The larger one measured 3 by I by 1 cm. and consisted of firm, gray-white, cauliflower-surfaced, hypertrophic gingival tissue removed from the lingual gingival mucosa of the upper left incisor area. The smaller specimen was similar in appearance and was from the labial alveolar gingival mucosa of the upper left incisor area.
540
Knapp
md
Uoharn
Fig. 2. Labial involvement of maxillary and mandibular gingival Fig. 3. Lingual involvement of maxillary gingival tissues.
OS., O.M. c O.P. April, 1967
tissues.
Fig.
‘ig. 5
Fig.
“ig. 7
Fig. Fig. Fig. minimal Fig.
4. Overlapping lesion at lower mucogingival junction. 5. Satellite lesions on lower left vestibular mncosa. 6. Contiguous lesion on lower right buccinator frenulum involvement of upper right interdental papillae. 7. Lower lingual gingival involvement.
from
gingival
lesion
and
Volume Number
23 4
Oral condyloma acuminatum
Fig.
Fig . 8
Fig.
Fig.
9
Fig. Fig. Fig. Fig. satellite
541
8. Maxillary surgical area. 9. Labial (top) and lingual (bottom) gross specimens. 10. Immediate lower right surgical site and calculus deposition. 11. Lower left lingual gross specimen (top) and lower left lesions (bottom).
labial
specimen
with
Vicrosoopic. No keratinized layer was visualized, although there was scanty focal parakeratosis. Generally, the epithelial layer exhibited tremendous acanthosis and was seen in a pattern of papillomatosis (papillary acanthosis) or in undulating folds (Fig. 12). Many epithelial rete pegs were elongated; some were notably blunted and exhibited minimal to marked branching in random areas (Fig. 13). Many vacuolated squamous cells with clear cytoplasm and centrally placed hyperchromatic nuclei were seen in the upper hyers of the stratum spinosum (Fig. 14). The cells of all epithelial layers showed an orderly maturation pattern with no evidence of malignant dyskeratosis. The basement membrane was intact (Fig. 15). A chronic inflammatory-cell infiltrate, as well as many small dilated vessels, was seen in the papillary and reticular layers of the lamina propria. The lesion was diagnosed as condyloma acuminatum of the maxillary and mandibular mucogingival areas. Comment. Brown and Brown, Gomori methenamine silver, and Shorr’s stains were noncontributory.
DISCUSSION
Clinically, the gingival lesions appeared unique, exceptional, and unlike other gingival enlargements. The verrucous and rough surface texture and the bulbous contours encompassing the greatest extent of the involved attached gingiva were firm and of the same color as normal gingival mucosa. The bor-
11
542
Knapp
and
Uohara
ders of the lesions were irregular but well dcmsrcatc~tl ant1 readily tlisc*rrnil)lc from normal mucosa. The lesions appeared similar to papillomntosis, reprcsenting extensive epithelial tissue participation, instcatl of fibrosis as seen in other enlargements where the connective tissue rcsponsc is primary. A jet of air on the lesion separated numerous lobules of varying sizes closely approximating one another. Of significant interest were the several satellite lesions, as well as the contiguous growths on the alveolar mucosa suggesting an active process and a
Fig.
1%
Fig.
13
Fig.
lb. Papillary
acanthosis.
(Hematoxylin
and eosin stain.
Magnification,
x24;
reduced
1%) Fig. 13. Marked stain. Magnification,
blunting and branching x24; reduced ya,)
of epithelial
rete pegs. (Hematoxylin
and eosin
Volume 23 Number 4
Oral cordyZoma acuminatum
543
possible mode of extension of the original lesion (Figs. 5 and 16). The satellite lesions and the recurrence were highly suggestive of a viral cause. In spite of clinical dissimilarity to any reported hyperplastic conditions of the gingiva, the following gingival enlargements were considered in the differential diagnosis but were discounted for the reasons given : Dilantin hyperplasia, discounted on the basis of no medication; hereditary fibromatosis, ruled out because of the negative family history and incomplete involvement; leukemia, rejected because of the negative complete blood count and clinical history; hyper-
Fig.
14
Fig.
15
Fig. 14. Vacuolated cells in stratum spinosum. (Hematoxylin and eosin stain. Magnification, x75; reduced 1/.) Fig. 15. Intact basement membrane with subjacent inflammatory cell infiltrate. (Hematoxylin and eosin stain. Magnification, x120; reduced M.)
O.R.,O.M. & 0.1’.
544 Knapp and Uohara
April,
Pig. 16. Transition from normal mucous mcml)rane eosin stain. Magnification, x14; reduced 1h.j
to sa.tellito
1967
1esio11. (Ikmatoxylin
and
plasia from chronic periodontitis and hypertrophic gingivitis, ruled out because of the clinical appearance and the x-ray findings which were inconsistent with clinical findings. because of Papillary hyperplasia of the gingiva” was considered initially its similar clinical appearance. This was ruled out, however, on the strength of a comparative histologic study. Generally, it is observed that calculus is a definite exciting factor in many hypertrophic conditions of the gingiva. Calculus was not a major contributory factor in this lesion, however, since the maxillary and mandibular hypertrophic responses were approximately equal (Figs. 9 and 11) in spite of the fact that calculus deposition was heavy in the lower arch and minimal in the upper arch (Figs. 8 and 10). Histologic differentiation of condyloma acuminatum from verruca vulgaris poses no problem. Moreover, simple condyloma lacks the clinical behavioristic properties and histologic patterns to be considered in differentiating it from the invasive acanthomas. The histologic findings in this case were identica1 to the histologic criteria of condyloma acuminatum in the anogenital regions. Since the mouth is lined with epithelium similar to that of the a.nogenital mucosa, there is no reason why changes in the oral tissues cannot parallel their counterparts in other areas. As examples, similar oral and anogenital mucosal changes are seen in white sponge nevus, lichen planus, Addison’s disease, monilia infections, and erythema, multiforme. There is little reason to doubt that simple condyloma acuminatum may occur on the oral mucosa. Thus, the occurrence of oral condyloma must be considered in a differential diagnosis of hyperplastic responses in the oral cavity. *An inflammatory possible viral etiology.
papillary An article
hyperplasia of the gingival and contiguous on this is in preparation for publication.
tissues
of
Volume 23 K’umber 4
Oral condyloma acuminatum
545
COMMENT Since the lesion of condyloma acuminatum is autoinoculable and transmissible, the possibility of oral-genital contact as the mode of spread was considered. However, this was ruled out on obtaining a negative history from the patient. This case illustrates the necessity of removing pathologic growths for histologic study which, together with clinical observation, will establish a definitive diagnosis. Only then can treatment be removed from the realm of empiricism and placed on a rational basis. REFERENCES
I. Lund, Herbert Z.: Tumors of the Skin (Atlas of Tumor Pathology, Sect. 1, Fast. 2), Washington, 1957, Armed Forces Institute of Pathology, pp. 25, 27. :?. Andrews, George C., and Domonkos, Anthony N.: Diseases of the Skin, Philadelphia, 1963, W. B. Saunders Company, pp. 410-413. 3. Lever, Walter F.: Histopathology of the Skin, Philadelphia, 1961, J. B. Lippincott Company, pp. 308-313. 4. Pillsbury, D. W., Shelley, W. B., and Kligman, A. M.: Dermatology, Philadelphia, 1960, W. B. Saunders Company., pp. 690-693. !j. Goldschwidt, H., and Khgman, A. M.: Experimental Inoculation of Humans With Ectodermotrophic Viruses, J. Invest. Dermat. 31: 175-182, 1958. 6. Allen, Arthur C.: The Skin, St. Louis, 1954, The C. V. Mosby Company, p. 708. ‘7. Dawson, D. F., Duckworth, a. K., Bernhardt, H., and Young, J. H.: Giant Condyloma and Verrucous Carcinoma of the Genital Area, Arch. Path. 79: 225-231, 1965. .3. Seibert, Jay S.: Personal Communication.
of the
Federal dental services
Oral condyloma acuminatum Milton J. Knapp, Lieutenant Colonel, DC, USA,* and George I. Uohara, Lieutenant Colonel, DC, USA”” UNITED
STATES
ARMY
ARMOR
CENTER,
FORT
KNOX,
KY.
W
arts are virus-induced epithelial growths of the integument and mucous membranes. Generally, they are separated into four clinical varieties: (l)verruca vulgaris, the papillary wart found commonly on the hands of the young and less commonly on the lips and oral mucous membranes ; (2) verruca plana, the flat or plane wart most commonly affecting the face and dorsa of the hands in childhood; (3) verruca plantaris, the hyperkeratotic excrescences frequently occurring at pressure sites ; and (4) condyloma acuminatum, the warty growths which occur in the warm, moist, intertriginous areas about the genitals or anus.l-” The occurrence of verruca vulgaris in the oral cavity is well established. Of the remaining types of verruca it appears reasonable that condyloma acuminatum would occur on the oral mucosa with a relative degree of frequency. Verruca vulgaris and condyloma acuminatum are similar in origin ; they occur on the skin and mucous membra,nes; some spontaneous regression may be seen in each; and both are transmissible and auto-inoculable.5 HOWever, a review of the literature reveals no reported incidence of condyloma acuminatum of the oral mucous membranes. Condyloma acuminatum is a papillomatous growth which occurs most frequently on anogenital skin and mucosa but may also involve other warm, moist, intertriginous areas. These lesions may appear singly or as soft, pink, papillomatous clusters of varying sizes and proportion@ (Fig. 1). Condylomas generally respond readily to treatment wit,h podophyllin, but there is a tendency toward multiple local recurrences.7 The opinions or assertions contained in this article are the private ones of the writers and are not to be construed as official or reflecting the views of the Department of the Army or the Defense Department at large. *Chief, Oral Pathology, Dental Detachment. **Chief, Periodontics, Dental Detachment.
538
Volume Number
0ra.l condyloma acumhatum
23 4
Pig. 2. Papillomatous
clusters
539
on penis.
CASE REPORT An 1%year-old well-nourished, well-developed Caucasian soldier reported to the dental clinic for examination with the chief complaint of “enlarged gums” of many years’ duration. Extraoral examination findings and the family history were unremarkable. Physical examination revealed a well-developed, slender, well-oriented Caucasian male in no apparent distress. The patient was under no medical treatment and was taking no medication. Fxamination of the skin, including the anogenital area, was entirely negative. The results of all laboratory tests, including a complete blood count, urinalysis, and serologic and bacteriologic studies were within normal limits. The remainder of the examination was noncontributory. Laboratory tests were repeated, with negative results. Intraoral examination revealed extremely poor oral hygiene, with multiple caries and heavy deposition of calculus. The maxillary gingiva presented a firm, verrucous enlargement of the gingival tissues, extending from the midline to the mesial aspect of the upper left second premolar, encroaching in the in&al area to the mucogingival junction (Fig. 2). Palatally, the lesion extended to the same limits, with pronounced involvement of the lateral incisor and cuspid areas (Fig. 3). Involvement of the mandibular gingiva extended from the mesial aspect of the left first molar to the medial aspect of the right second premolar. The entire attached gingiva in this area was involved, and the convexity of its bulbous configuration overlapped beyond the mucogingival junction (Fig. 4). Intraoral roentgenograms and examinations revealed periodontitis with minor bone loss. In addition, satellite lesions extended into the areas of the buccinator frenula bilaterally (Figs. 5 and 6). In the lower lingual aspect, the verrucous growth extended to areas corresponding to the labial involvement (Fig. 7). Clinically, the entire lesion exhibited various degrees of chronic inflammation. The interdental papilla of the upper right incisor area revealed minimal involvement (Fig. 6). Other oral soft tissues and the oropharynx were not involved. Periodontal surgical treatment was accomplished in two visits. At the first visit the entire maxillary involved gingiva, including part of the periosteum, was removed (Figs. 8 and 9). The surgical area was carefully curetted, scaled, irrigated, and dressed with surgical pack. A similar procedure was performed on the mandibular gingiva and mucosa ((Figs. 10 and 11). Healing was rapid and uneventful. Subsequent to the surgical procedure, the patient was transferred to another station. An 8 month follow-up report indicated that the lesion on the lower lingual gingiva had recurred, extending onto the mucosa of the floor of the mouth.8 Pathology
report
Gross. Two specimens were submitted. The larger one measured 3 by I by 1 cm. and consisted of firm, gray-white, cauliflower-surfaced, hypertrophic gingival tissue removed from the lingual gingival mucosa of the upper left incisor area. The smaller specimen was similar in appearance and was from the labial alveolar gingival mucosa of the upper left incisor area.
540
Knapp
md
Uoharn
Fig. 2. Labial involvement of maxillary and mandibular gingival Fig. 3. Lingual involvement of maxillary gingival tissues.
OS., O.M. c O.P. April, 1967
tissues.
Fig.
‘ig. 5
Fig.
“ig. 7
Fig. Fig. Fig. minimal Fig.
4. Overlapping lesion at lower mucogingival junction. 5. Satellite lesions on lower left vestibular mncosa. 6. Contiguous lesion on lower right buccinator frenulum involvement of upper right interdental papillae. 7. Lower lingual gingival involvement.
from
gingival
lesion
and
Volume Number
23 4
Oral condyloma acuminatum
Fig.
Fig . 8
Fig.
Fig.
9
Fig. Fig. Fig. Fig. satellite
541
8. Maxillary surgical area. 9. Labial (top) and lingual (bottom) gross specimens. 10. Immediate lower right surgical site and calculus deposition. 11. Lower left lingual gross specimen (top) and lower left lesions (bottom).
labial
specimen
with
Vicrosoopic. No keratinized layer was visualized, although there was scanty focal parakeratosis. Generally, the epithelial layer exhibited tremendous acanthosis and was seen in a pattern of papillomatosis (papillary acanthosis) or in undulating folds (Fig. 12). Many epithelial rete pegs were elongated; some were notably blunted and exhibited minimal to marked branching in random areas (Fig. 13). Many vacuolated squamous cells with clear cytoplasm and centrally placed hyperchromatic nuclei were seen in the upper hyers of the stratum spinosum (Fig. 14). The cells of all epithelial layers showed an orderly maturation pattern with no evidence of malignant dyskeratosis. The basement membrane was intact (Fig. 15). A chronic inflammatory-cell infiltrate, as well as many small dilated vessels, was seen in the papillary and reticular layers of the lamina propria. The lesion was diagnosed as condyloma acuminatum of the maxillary and mandibular mucogingival areas. Comment. Brown and Brown, Gomori methenamine silver, and Shorr’s stains were noncontributory.
DISCUSSION
Clinically, the gingival lesions appeared unique, exceptional, and unlike other gingival enlargements. The verrucous and rough surface texture and the bulbous contours encompassing the greatest extent of the involved attached gingiva were firm and of the same color as normal gingival mucosa. The bor-
11
542
Knapp
and
Uohara
ders of the lesions were irregular but well dcmsrcatc~tl ant1 readily tlisc*rrnil)lc from normal mucosa. The lesions appeared similar to papillomntosis, reprcsenting extensive epithelial tissue participation, instcatl of fibrosis as seen in other enlargements where the connective tissue rcsponsc is primary. A jet of air on the lesion separated numerous lobules of varying sizes closely approximating one another. Of significant interest were the several satellite lesions, as well as the contiguous growths on the alveolar mucosa suggesting an active process and a
Fig.
1%
Fig.
13
Fig.
lb. Papillary
acanthosis.
(Hematoxylin
and eosin stain.
Magnification,
x24;
reduced
1%) Fig. 13. Marked stain. Magnification,
blunting and branching x24; reduced ya,)
of epithelial
rete pegs. (Hematoxylin
and eosin
Volume 23 Number 4
Oral cordyZoma acuminatum
543
possible mode of extension of the original lesion (Figs. 5 and 16). The satellite lesions and the recurrence were highly suggestive of a viral cause. In spite of clinical dissimilarity to any reported hyperplastic conditions of the gingiva, the following gingival enlargements were considered in the differential diagnosis but were discounted for the reasons given : Dilantin hyperplasia, discounted on the basis of no medication; hereditary fibromatosis, ruled out because of the negative family history and incomplete involvement; leukemia, rejected because of the negative complete blood count and clinical history; hyper-
Fig.
14
Fig.
15
Fig. 14. Vacuolated cells in stratum spinosum. (Hematoxylin and eosin stain. Magnification, x75; reduced 1/.) Fig. 15. Intact basement membrane with subjacent inflammatory cell infiltrate. (Hematoxylin and eosin stain. Magnification, x120; reduced M.)
O.R.,O.M. & 0.1’.
544 Knapp and Uohara
April,
Pig. 16. Transition from normal mucous mcml)rane eosin stain. Magnification, x14; reduced 1h.j
to sa.tellito
1967
1esio11. (Ikmatoxylin
and
plasia from chronic periodontitis and hypertrophic gingivitis, ruled out because of the clinical appearance and the x-ray findings which were inconsistent with clinical findings. because of Papillary hyperplasia of the gingiva” was considered initially its similar clinical appearance. This was ruled out, however, on the strength of a comparative histologic study. Generally, it is observed that calculus is a definite exciting factor in many hypertrophic conditions of the gingiva. Calculus was not a major contributory factor in this lesion, however, since the maxillary and mandibular hypertrophic responses were approximately equal (Figs. 9 and 11) in spite of the fact that calculus deposition was heavy in the lower arch and minimal in the upper arch (Figs. 8 and 10). Histologic differentiation of condyloma acuminatum from verruca vulgaris poses no problem. Moreover, simple condyloma lacks the clinical behavioristic properties and histologic patterns to be considered in differentiating it from the invasive acanthomas. The histologic findings in this case were identica1 to the histologic criteria of condyloma acuminatum in the anogenital regions. Since the mouth is lined with epithelium similar to that of the a.nogenital mucosa, there is no reason why changes in the oral tissues cannot parallel their counterparts in other areas. As examples, similar oral and anogenital mucosal changes are seen in white sponge nevus, lichen planus, Addison’s disease, monilia infections, and erythema, multiforme. There is little reason to doubt that simple condyloma acuminatum may occur on the oral mucosa. Thus, the occurrence of oral condyloma must be considered in a differential diagnosis of hyperplastic responses in the oral cavity. *An inflammatory possible viral etiology.
papillary An article
hyperplasia of the gingival and contiguous on this is in preparation for publication.
tissues
of
Volume 23 K’umber 4
Oral condyloma acuminatum
545
COMMENT Since the lesion of condyloma acuminatum is autoinoculable and transmissible, the possibility of oral-genital contact as the mode of spread was considered. However, this was ruled out on obtaining a negative history from the patient. This case illustrates the necessity of removing pathologic growths for histologic study which, together with clinical observation, will establish a definitive diagnosis. Only then can treatment be removed from the realm of empiricism and placed on a rational basis. REFERENCES
I. Lund, Herbert Z.: Tumors of the Skin (Atlas of Tumor Pathology, Sect. 1, Fast. 2), Washington, 1957, Armed Forces Institute of Pathology, pp. 25, 27. :?. Andrews, George C., and Domonkos, Anthony N.: Diseases of the Skin, Philadelphia, 1963, W. B. Saunders Company, pp. 410-413. 3. Lever, Walter F.: Histopathology of the Skin, Philadelphia, 1961, J. B. Lippincott Company, pp. 308-313. 4. Pillsbury, D. W., Shelley, W. B., and Kligman, A. M.: Dermatology, Philadelphia, 1960, W. B. Saunders Company., pp. 690-693. !j. Goldschwidt, H., and Khgman, A. M.: Experimental Inoculation of Humans With Ectodermotrophic Viruses, J. Invest. Dermat. 31: 175-182, 1958. 6. Allen, Arthur C.: The Skin, St. Louis, 1954, The C. V. Mosby Company, p. 708. ‘7. Dawson, D. F., Duckworth, a. K., Bernhardt, H., and Young, J. H.: Giant Condyloma and Verrucous Carcinoma of the Genital Area, Arch. Path. 79: 225-231, 1965. .3. Seibert, Jay S.: Personal Communication.