Squamous papillomas are common lesions of the oral mucosa related to human papilloma virus even though the controversy regarding its pathogenesis still exists. It most often occurs on the tongue and the hard palate. It is important to diagnose it correctly as it may mimic malignant lesions. Here we present a case of oral squamous cell papilloma and its review.
A 75 year male patient reported to the clinic with a chief complaint of a growth over the right side of the tongue since 1 year. The growth was associated with a dull pain and a mild discomfort in speech and deglutition. Initially it was small in size later it grew larger and reduced in its size after undergoing extraction of few teeth nearer to it.
On extra oral examination, there was reduced vertical dimension of the face (Figure 1). Intraoral examination revealed an exophytic tissue growth in relation to right lateral border of tongue of size 2*2 cm, extending over to the ventral surface of the tongue. Surface of the tongue appeared fissured and lobulated. A linear white keratotic area was seen over the right lateral and ventral aspect of the tongue (Figure 2). On palpation, slight tenderness was present. Base appeared indurated and firm in consistency. The white keratotic area was non scrapable and non tender. After clinical examination, a provisional diagnosis of malignant lesion of the tongue was given with a TNM staging of T1N0M0.
Toluidine blue staining was done and the lesion did not take up the stain (Figure 3). The patient was referred to an oral surgeon for excisional biopsy, where the histopathological analysis revealed multiple finger like projections of stratified squamous epithelium exhibiting hyperkeratosis and keratin plugging. The underlying connective tissue entrapped within the papillary projections showed chronic inflammatory infiltrate. Based on the clinical and histopathological report, the final diagnosis given was Squamous Papilloma of the tongue.
Among the papillary lesions of oral mucosa, it is the
commonest. It is estimated that 4 in 1000 persons exhibit oral
squamous papilloma. It is usually reported in the age group of
30-50 years, unlike our case which was seen in a 65 year old
male patient. There is equal sex incidence, even though few
studies show slight male predilection . The whitish color of
the lesions indicates the thickness of the cornified layer which
was seen in our case too .
It is caused by Human Papillomavirus (HPV) types 6 and 11
(HPV 6 and HPV 11) which is less virulent and with low infectivity
rate. The pathogenesis is that, the double stranded viral DNA
integrates with the host DNA leading to the development of
The lesion often presents as a well circumscribed, solitary
exophytic growth with a, roughened or wart like surface. The
surface either has numerous small finger-like projections or may
be blunted. It is seen almost always as a pedunculated lesion
but can be sessile occasionally. It is mostly painless. Depending
on the thickness of keratinization, the appears white or pink.
Sometimes the surface appears reddened due to trauma. The
lesion often measures from a few millimetre to less than 1cm in
diameter but sometimes large lesions can be seen .
Electron microscopic analysis is preferred over conventional
biopsy. The other methods of detection are in situ hybridization,
immunohistochemistry and polymerase chain reaction (PCR)
technique . It is lined by well ordered stratified squamous
epithelium. There is perinuclear cytoplasmic vacuolisation
of spinous cells which are surrounded by optically clear zone
forming perinuclear pale halos and pyknosis. The connective
tissue is fibrovascular in nature with chronic inflammatory cell
The preferred treatment is surgical excision. Either
routine excision or laser ablation can be used. Other treatment
modalities include electrocautery, cryosurgery, and intralesional
injections of inter-feron. Recurrence is not common, except in
patients infected with human immunodeficiency virus (HIV) .