verrucal papillary disease

• Verrucal


  Relating to or resembling a wart
• Papillary


  Relating to or resembling a papilla
• Learning Objectives


  • Knows how to identify the lesions
  • Knows how to classify the lesions
  • Understand the histopathology of each lesion
  • Recognize the treatment options of each lesion
• Types of Lesions


  • Idiopathic
  • Neoplastic
  • Reactive/Infective
• Squamous Papilloma (Verruca vulgaris)


  • Most common (2.5% of all oral lesions)
  • Associated with HPV (non-oncogenic types 2,6,11 &37)
  • On vermilion border of lip or any intraoral mucosal sites
  • Hard & soft palate & uvula in (50% of lesions)
  • Less than 1 cm, pink-white exophytic granular or cauliflower-like surface alteration
  • Solitary, asymptomatic
  • Oral warts increased in HIV/AIDS patients

  
• Koilocytes


  Cells with pyknotc nuclei, surrounded by an edematous or clear zone, indicative of a virally altered state

  
• Papillary Hyperplasia ("Palatal Papillomatosis")


  • Exclusive in hard palate, always associated with removable prosthesis
  • Due to low grade chronic trauma with fungal infection under ill fitting dentures
  • Multiple erythematous & edematous papillary projections producing an overall verrucous, granular or cobble-stone appearance

  
• Condylomata Latum


  • Expression of secondary syphilis
  • Exophytic, friable, papillary to polypoid lesions within oral cavity
  • Potentially infectious (abundant T pallidum)
  • Perianal & genital area are the usual sites

  
• Condylomata Accuminatum


  • Infectious lesion in anogenital & oral regions (Venereal wart)
  • Seen in HIV-infected patients (opportunistic)
  • Caused by HPV 6 & 11
  • Soft broad-base exophytic, papillary growth (keratinized or non-keratinized)

  
• Focal Epithelial Hyperplasia ("Heck's Disease")


  • Due to low-grade irritation, vitamin deficiency with HPV 13 & 32 infection
  • Numerous nodular soft tissue masses distributed over mucosal surfaces (buccal, labial mucosa, tongue & gingiva)
  • Discrete or clustered papules with same color of surrounding oral mucosa

  
• Pyostomatitis Vegetans


  • Benign, chronic, pustular form of mucocutaneous disease, mostly in association with inflammatory bowel diseases
  • Unknown cause, males at 6th decade
  • Involve gingiva, hard & soft palate, buccal & labial mucosae
  • Buccal mucosa appear as erythematous, edematous, nodular & occasionally fissured
  • Numerous tiny yellow pustules (2-3 mm) & small vegetating papillary projections may be seen over the surface of friable mucosa

  
• Verruciform Xanthoma


  • Uncommon, benign oral mucosal lesions, skin & genitalia
  • Unknown cause, age of onset is 45 years
  • Well circumscribed lesion with granular to papillary surface
  • Size 2 mm to 2cm
  • Color range from white to red

  
• Verrucous Carcinoma


  • Closely associated with the use of tobacco of various forms
  • HPV has a role
  • Account for 5% of all intra oral SCC
  • Site: buccal mucosa (most common), then gingiva (especially mandibular)
  • Male over 50 years
  • Early lesion: As verrucous hyperplasia (white, indurated with irregular borders)
  • Late lesions: Exophytic with white-gray shaggy surface

  
• Keratoacanthoma


  • Squamo-proliferative lesion of unknown cause mainly in sun-exposed skin & sometimes at mucocutaneous junction, rare in oral mucous membrane
  • On skin: It originates within pilosebaceous apparatus
  • Orally: Buccal mucosa >gingiva > tongue > palate
  • Solitary or multiple, begins as small, red macule which soon become a firm papule with a fine scale over its heighest point
  • Fully developed lesion: contain a core of keratin surrounded by a concentric collar of raised skin or mucosa
  • If lesions not removed, spontaneous regression occur
  • The central keratin mass is exfoliated, leaving a cup-shaped lesion which heals with superficial scar formation

  
• Basal Cell Carcinoma


  • Incidence US 500-1000 per 100,000
  • Over 400,000 new patients annually
  • Age usually over age 40
  • Sex Males >Females
  • Race rare in brown and black skinned patients
  • Types: Superficial BCC, Nodular BCC, Pigmented BCC, Cystic BCC, Sclerosing or Morpheaform BCC, Recurrent BCC
• Malignant Melanoma


  • Peak incidence between 40-60 years
  • Usually appear as black or brown patches
  • UV exposure, fair complexion & sun sensitivity (well recognized etiological factors for coetaneous melanoma)
  • Mucosal melanoma are common in India, Japan & Africa
  • Amelanotic melanoma appear red
  • Intraoral site: Palate & upper alveolar ridge
  • Oral Melanoma is flat or raised nodular lesion which later cause soreness & bleeding
  • Grows in predictable manner: Radial or horizontal growth phase (pre invasive or in situ stage), Vertical growth phase (Invasive stage)
  • 30% of melanomas preceded by an area of hyperpigmentation, often by many years

  
• Clinicopathological types of melanoma


  • Superficial spreading melanoma (Radial growth phase), most common cutaneous melanoma
  • Nodular melanoma (Vertical growth phase), 1/3 develop in head & neck region
  • Lentigo maligna melanoma (Radial growth phase), develop from precursors Hutchinson's freckles in sun exposed, fair complexioned skin in mid facial area
  • Acral Lentiginous melanoma (Radial growth phase), most common in blacks, most common form of oral melanoma, darkly pigmented, irregular margin nodule

  
• ABCDE system of evaluation


  • Asymmetry (because of uncontrolled growth pattern)
  • Border irregularity (often with notching)
  • Color variation (from brown-black, white, red & blue)
  • Diameter (greater than 6 mm)
  • Evolving (lesion changes over time)