Journal of Medicine, Radiology, Pathology & Surgery (2019), 6, 18–21

CASE REPORT

Oral squamous papilloma in a pediatric patient: A case

report and review
Kaushik Ranjan Deb1, D. B. Nandini1, Koijam Sashikumar Singh2
Department of Oral Pathology, Dental College, Regional Institute of Medical Sciences, Imphal, Manipur, India, 2Department of Oral Medicine and Radiology,
1

Dental College, Regional Institute of Medical Sciences, Imphal, Manipur, India

Keywords: Abstract
Clinical features, diagnosis, etiology, Squamous papillomas are benign exophytic lesions that are commonly found in the oral
histopathology, human papillomavirus,
cavity. Although the exact etiology of the lesion is not known, an association with human
koilocytes, pediatric patient, squamous
papillomavirus (HPV) infection is suggested. On the contrary, some recent studies have
papilloma
showed no correlation between HPV and squamous papilloma. This article presents a
Correspondence: case of 4-year-old male patient who reported with a papillary lesion on the palatal gingival
Dr. Kaushik Ranjan Deb, Dental College, which was diagnosed as oral squamous papilloma by histopathologic examination.
Regional Institute of Medical Sciences,
Imphal, Manipur, India.
Phone: +91-9612791819, 7005619441.
E-mail: kaushikranjandeb1994@gmail.com

Received: 12 December 2018;

Accepted: 29 January 2019

Doi: 10.15713/ins.jmrps.157

Introduction Case Report

Squamous papilloma is a benign lesion exhibiting exophytic
verrucopapillary growth. These are the most common
benign epithelial tumors of the oral mucosa which account
for 3–4% of all the biopsied lesions.[1] The common sites of
occurrence include the dorsum and lateral borders of tongue,
followed by palatal mucosa, gingiva, buccal mucosa, lower
lip, and uvula.[2] Although the exact etiology is not known,
trauma and a persistent infection of human papillomavirus
(HPV) are suggested.[3] Some studies suggested that the
presence of HPV may be an incidental finding which is not
related to the etiology of squamous papilloma. Majority of
HPV-associated lesions manifest as exophytic growths with
finger-like projections and are mostly associated with low-
risk HPV Types 6, 11, 13, and 32 and high-risk HPV Types
16, 18, 31, 33, and 35. The high-risk types pose a greater risk
of malignant transformation. HPV-associated lesions include
anogenital warts, cancer of the oropharynx, dysplasia, and
cervical cancer.[4]
A 4-year-old male child accompanied with his parents reported to
the outpatient department of our college with a chief complaint
of multiple decayed teeth along with a small tissue growth in
the upper front teeth region for 3 months. His past medical and
dental history were insignificant. All the vitals were in the normal
range, and growth milestones were also normal.
The patient was apparently normal 3 months back after which his
parents noticed a small growth in his upper front teeth region which
gradually increased to its present size. The lesion is asymptomatic.
On intraoral examination, a solitary exophytic growth was evident
on the palatal gingival on the mesiopalatal aspect of 51 with grossly
decayed 51, 52, 53, 54, 61, 62, 64, 74, and 85, and pulp polyps in
relation to 62 and 54 were observed [Figures 1 and 2].
There was no extraoral finding. On inspection, the exophytic
growth was a solitary lesion with a sessile base, measuring
about 1.5 × 8 mm in diameter and pale pink with irregular
papillary projections on its surface. On palpation, the lesion
was soft to firm in consistency, and non-tender and showed
no bleeding or ulceration. A provisional clinical diagnosis

18 Journal of Medicine, Radiology, Pathology & Surgery  ●  Vol. 6:1  ●  Jan-Feb 2019
Pediatric oral squamous papilloma
of squamous papilloma was made. Excisional biopsy was
performed [Figure 3], and the tissue was sent for histopathologic
examination. Histopathologic examination of the submitted
Figure 1: Clinical intraoral photograph of the lesion from frontal
aspect
Figure 2: Clinical intraoral photograph of the lesion from occlusal
aspect
Figure 3: Surgical excision of the exophytic growth
Journal of Medicine, Radiology, Pathology & Surgery  ●  Vol. 6:1  ●  Jan-Feb 201919
Deb, et al.
tissue specimen revealed hyperplastic parakeratinized stratified
squamous epithelium with papillary projections on the surface
enclosing thin fibrovascular connective tissue cores suggestive of
squamous papilloma. Chronic inflammatory cells were evident
in the connective tissue cores [Figures 4 and 5]. The underlying
connective tissue was fibrocellular with moderate vascularity.
Discussion
Oral squamous papilloma is a painless, well-defined exophytic
growth presenting with a sessile or pedunculated base. Clinically,
these lesions appear pink to white depending on the degree
of keratinization, usually measuring <1 cm in size and show
characteristic finger-like surface proliferations.[5] Most common
sites of occurrence in the oral cavity are tongue and palate.
Figure  4: Photomicrograph revealing multiple finger-like
proliferations with thin fibrovascular connective tissue cores
(10 × magnification, hematoxylin and eosin stain)
Figure  5: Photomicrograph revealing finger-like epithelial
proliferation with a thin connective tissue core showing chronic
inflammatory cell infiltrate (20 × magnification, hematoxylin and
eosin stain)
Deb, et al.
This lesion is most often seen in individuals with an age range
of 20–50 years without any gender predilection. Squamous
papillomas are classified into two types: Isolated-solitary and
multiple-recurring type. Solitary lesions are common in adults,
and multiple lesions are more common in children. These
lesions are usually painless unless large enough to cause occlusal
interference or difficulty in eating.
HPV infection is thought to play an important role in the
development of squamous papilloma. Low-risk types of HPV
6 and 11 are usually associated with oral squamous papilloma.
Squamous papillomas are often diagnosed in the second to
fourth decade of life.[6] It is suggested that these lesions are
more frequent in people with active sexual life. Squamous
papilloma has been reported in children of <1 year and children
younger than 19  years of age with significant level of HPV
infection. There are many suggested ways of viral transmission
in children. A vertical transmission of HPV infection from
mother to child prenatally through hematogenous route or by
aspiration of amniotic fluid during child birth is suggested. Post-
natal transmission due to auto or heteroinoculation by genital,
sexual, or casual social contact[7] and transmission through
saliva and oral sex are suggested for oral lesions. Possibility
of sexual abuse should be ruled out as well. On the contrary,
recent studies have reported no correlation between the
practice of oral sex and HPV infection. Squamous papillomas
have been reported in immunocompromised patients such as
HIV patients who may show recurrent lesions.[5] The presence
of papillomas in other mucocutaneous surfaces should also
be evaluated. No such features were present in this case, and
all possibilities were ruled out by obtaining a detailed history
from the parents which suggested a non-sexual transmission
mechanism.
Solitary oral squamous papilloma may clinically resemble
verruca vulgaris, verruciform xanthoma, papillary hyperplasia,
and condyloma acuminatum. Larger lesions may resemble
verrucous carcinoma, proliferative verrucous leukoplakia, and
squamous cell carcinoma. Differentiating squamous papilloma
from these high-risk lesions is essential. Verruciform xanthoma
may resemble oral squamous papilloma but has unique site of
occurrence in the gingival and alveolar mucosa and presence
of foam cells histologically. A  cause and effect relationship
(such as ill-fitting acrylic denture) should be evaluated for
inflammatory papillary hyperplasia. Condyloma acuminatum is
larger with broad base compared to the oral squamous papilloma
and associated with skin lesions. In addition, focal epithelial
hyperplasia (Heck’s disease) presents clustered or multiple
squamous papillomas.[5] Slow growth and absence of epithelial
dysplasia differentiate squamous papilloma from squamous cell
carcinoma.
Histological features of squamous papilloma reveal
hyperplastic epithelium with delicate fibrovascular cores, and
supporting stroma may show chronic inflammatory cells.
Some cellular atypia, basilar hyperplasia, and increased mitotic
activity in basal layer may be seen and may mislead to epithelial
dysplasia. HPV-altered cells, known as koilocytes, may or may
20
Pediatric oral squamous papilloma
not be seen. The presence of koilocytes indicates virally altered
state.[8] Koilocytes reveal a pyknotic nucleus with irregular
membrane and perinuclear halo representative of viral inclusion
with condensation of cytoplasm in the periphery.[8]
Viral presence can be confirmed by polymerase chain
reaction. The viral DNA can also be detected in the tissue
by in situ hybridization by the use of radioisotope-labeled
specific probes.[9,10] Viral inclusions may be appreciated by
special stains such as Macchiavello stain. Electron microscopy,
immunohistochemistry or molecular biology techniques such
as Southern blot and dot spot hybridization, enzyme-linked
immunosorbent assay, and indirect immunofluorescence are
other techniques of viral identification.[10]
A complete surgical excision including a rim of normal tissue is
the treatment of choice. Electrocautery, cryosurgery, intralesional
injections of interferon or laser ablation are other suggested
treatment methods.[11] These methods have advantages like
minimum bleeding, less need for anesthesia, faster postoperative
period and less trauma compared to conventional surgery. The
recurrence rate is very low for the solitary type compared with
multiple lesions. A histopathological examination to rule out the
dysplastic changes or frank malignancy is essential.
In the present case, a final diagnosis of squamous cell
papilloma was made based on the clinical presentation and
histopathology. After 6 months of follow-up, the patient has no
signs of recurrence.
Conclusion
Oral squamous papilloma is a common benign lesion
encountered in the clinical practice. Although the exact etiology
is unknown, association of HPV infection is suggested. These
benign lesions may resemble high-risk lesions such as squamous
cell carcinoma. Hence, differentiating papillomas from other
lesions are important. Early diagnosis and prompt treatment is
necessary to avoid complications.
References
1. Frigerio M, Martinelli-Kläy CP, Lombardi T. Clinical,
histopathological and immunohistochemical study of oral
squamous papillomas. Acta Odontol Scand 2015;73:508-15.
2. Abbey LM, Page DG, Sawyer DR. The clinical and histopathologic
features of a series of 464 oral squamous cell papillomas. Oral
Surg Oral Med Oral Pathol 1980;49:419-28.
3. De Gracia FW, Silva P, De Quieroz AM. Oral papilloma in
pediatric patients. Braz J Oral Sci 2006;5:938-40.
4. Varnai AD, Bollmann M, Bankfalvi A, Kovacs K, Heller H,
Schmitt C, et al. The prevalence and distribution of human
papillomavirus genotypes in oral epithelial hyperplasia:
Proposal of a concept. J Oral Pathol Med 2009;38:181-7.
5. Jaju PP, Suvarna PV, Desai RS. Squamous papilloma: Case report
and review of literature. Int J Oral Sci 2010;2:222-5.
6. Kennedy RA. HPV for the oral surgeon. Oral Surg 2016;9:4-9.
7. Pesántez J, Romero V, Lafebre F, Ramos VR, Carrasco JC.
Squamous papilloma in the oral cavity: Case presentation
Journal of Medicine, Radiology, Pathology & Surgery  ●  Vol. 6:1  ●  Jan-Feb 2019
Pediatric oral squamous papilloma
and review of the literature. J  Dent Health Oral Disord Ther
2018;9:257-60.
8. Neville BW, Damm DD, Allen CM, Bouquot JE. In: Koogan G,
editor. Oral and Maxillofacial Pathology. 2nd ed. Rio de Janeiro:
Elsevier; 2004. p. 304-5.
9. Kumar V, Abbas AK, Fausto N. Robbins and Cotran-Pathology
Basis of Disease. 7th ed. Rio de Janeiro: Elsevier; 2005. p. 357‑432.
10. Eversole LR, Laipis PJ. Oral squamous papillomas: Detection of
HPV DNA by in situ hybridization. Oral Surg Oral Med Oral
Journal of Medicine, Radiology, Pathology & Surgery  ●  Vol. 6:1  ●  Jan-Feb 201921
Deb, et al.
Pathol 1988;65:545-50.
11.
Yoshpe NS. Oral and laryngeal papilloma: A  pediatric
manifestation of sexually transmitted disease? Int J Pediatr
Otorhinolaryngol 1995;31:77-83.
How to cite this article: Deb KR, Nandini DB, Singh KS. Oral
squamous papilloma in a pediatric patient: A case report and
review. J Med Radiol Pathol Surg 2019;6:18-21.