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Case Report

Surgical Removal for Khat Inducible Verruca Vulgaris Lesion of the

Oral Mucosa
G Gazal

Department of Maxillofacial The harmful effects of khat chewing on the oral mucosa membrane are still

Abstract
Surgery, College of Dentistry,
Taibah University, Al
uncertain. Verruca vulgaris (common warts) is a benign lesion of skin and mucous
Madinah Al Munawwarah, membranes and can be caused by human papillomavirus. The lesions are typically
Saudi Arabia self‑limited but may vary in size and number. The occurrence on the floor of
mouth is extremely rare. To the best of our knowledge, there are few number of
oral lesions reported in connection with khat users. This case report shows that
the chronic khat chewing has contributed to the development of verruca vulgaris
warts that were confined to the chewing side of the mouth. A rare case of verruca
vulgaris of the floor of mouth occurring in a 27‑year‑old Yamani male is presented
with a discussion on etiopathogenesis and the treatment methods. Verruca vulgaris
must be remembered in the differential diagnosis of the floor of mouth lesions,
and surgical treatment may provide satisfactory outcomes.
Date of Acceptance:
08-Sep-2018 Keywords: Floor of mouth, human papillomavirus, khat, verruca vulgaris

Introduction presentation, the patient began feeling a small lump

T he chewing habit of khat leaves (Catha edulis)
can cause mucosal pathologies; however, there are
few reports on the oral findings due to this habit.[1] In
this case report, a case of verruca vulgaris associated
with heavy khat chewing is presented. Although human
papillomaviruses (HPVs) cause the most common
sexually transmitted infection and are responsible for
large number of cases with cervical cancer, it is still
considered as an important risk factor for oropharyngeal
and tongue cancer.[2] Several studies have demonstrated
a connection between HPV and oral cancer, which has
tremendous relevance in patient care, including treatment
and prevention of disease.[3‑6]
Case Presentation
A 27‑year‑old Yemeni male (camel shepherd) has been
referred to the screening clinic in the Taibah Dental
College, Al‑Madinah Al‑Munawarah for multiple
teeth extraction under local anesthesia in the 5th‑year
dental students’ clinic. This patient is a nonsmoker
and chews khat 3 times a day for 5 h since he was
15  years old. Medically, the patient was fit and well
and was not on any medication. Two years before
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in his mouth. Clinical examination revealed that
the patient has poor oral hygiene with generalized
periodontitis [Figure 1a-c]. There was a painless,
exophytic, sessile mass of 1.5 × 1.5 cm [Figure 2] on
the right side of the floor of the mouth  [Figure 3]. It
was in the middle of the distance between the base of
tongue and lower right second molar. The lesion was
isolated, not indurated, or having an ulcerated area
on mucosa membrane. There was no sign of lymph
nodes adenopathy. Under local anesthesia, the lesion
was excised totally using needle‑tip electrocautery
with preservation of safe surgical margins [Figure 4].
The patient did not have lesions elsewhere in the
body. The orthopantomogram (OPG) revealed that
the adjacent teeth were intact and not associated
with dental pathology. Diagnosis of verruca vulgaris
was confirmed by pathological investigation and
polymerase chain reaction analysis which revealed
Address for correspondence: Dr. G Gazal,
Department of Maxillofacial Surgery, College of Dentistry, Taibah
University, P.O. Box. 2898, Al Madina Al Munawara ‑ 41311,
Saudi Arabia.
E‑mail: gazal73@yahoo.co.uk
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DOI: 10.4103/njcp.njcp_357_18

How to cite this article: Gazal G. Surgical removal for khat inducible
PMID: ******* verruca vulgaris lesion of the oral mucosa. Niger J Clin Pract
2019;22:439-41.

© 2019 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 439

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Gazal: Khat inducible oral verruca vulgaris lesion
a b
Figure 1: (a-c) Poor oral hygiene and generalized periodontitis as a result of khat chewing
Figure 2: The size of the mass which is about of 1.5 × 1.5 cm
Figure 3: Exophytic, sessile lesion on the right side of the floor of the
mouth
Figure 4: The site of surgery with preservation of safe surgical margins
HPV‑4 DNA. Four months postoperatively, there were
no recurrences or complications sequelae.
440 Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 3  ¦  March 2019
c
Discussion
Various lesions may present on the floor of the mouth.
The effect of khat on the oral mucosa membrane was
reported by a few studies previously.[2‑6] However,
there is still lack of the evidence whether the khat
can cause oral leukoplakia or not. It must constantly
be kept in mind that early carcinoma frequently
appears as an area of erythroplasia, as 75–90% of
lesions prove to be carcinoma/carcinoma in situ or
are severely dysplastic.[4,5] The incidence of malignant
change is 17 times higher in erythroplasia than in
leukoplakia.[6] Several studies have reported that khat
chewing is considered as a harmful activity on health.
Many different compounds are found in khat including
alkaloids, terpenoids, flavonoids, sterols, glycosides,
tannins, amino acids, vitamins, and minerals. The
major pharmacologic and toxic effects come from the
phenylalkylamines and the cathedulins.[7] The major
effects of khat include those on the gastrointestinal
system and central nervous system but also affect the
cardiovascular, respiratory, endocrine, and genitourinary
systems.[7,8] The effects on the central nervous system
resemble those of amphetamine with differences
being quantitative.[8] The main toxic effects include
increased blood pressure, tachycardia, insomnia,
anorexia, constipation, general malaise, irritability,
migraine, and impaired sexual potency in men.[9] Since
this is a major social issue particularly in East Africa,
raising awareness with the general public, in terms
of the harmful effects of khat chewing,[5‑8] can be
accomplished via appropriate communication strategies
by using printed materials and electronic media.[8]
The clinical differential diagnosis of this case
included verrucous leukoplakia, verrucous carcinoma,
candidiasis (speckled white‑on‑red appearance),
and squamous papilloma. Microscopically, the
histopathological report showed that the lesion is verruca
vulgaris (common viral wart), and no sign of atypia was
seen.
There are two possible accounts for the explanation
of the effects of khat chewing on the rapid onset of
the oral viral infection. First, verruca vulgaris is a
virus‑induced neoplasm of the skin caused by a human
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Gazal: Khat inducible oral verruca vulgaris lesion
papilloma virus. According to Halboub et al.,[10] khat
chewing causes stomatitis that might be secondarily
infected. It also causes periodontitis, teeth discoloration,
and xerostomia.[9] So, the frictional trauma caused by
the khat chewing might create rough areas in the oral
mucosa, which in turn produce rapid proliferation of
viruses.
Second, chronic khat chewing and the chemical
composition of khat cause frictional keratosis with
severe corrugation.[1,3,7,10] The corrugation can be as
a result of absorption of irritating substances of khat
and continuous stretching of the oral mucosa collagen
fibers during chewing sessions. These corrugations
will form a resort to the increasing number of human
papilloma viruses. The viral infection will aggravate
the intracellular inflammation reaction, and as a
consequence, enlargement in the size of the lesion will
occur.[8,9,10]
Conclusion
Chronic khat chewing has contributed to the development
of verruca vulgaris warts that were confined to the
chewing side of the mouth. Surgical excisional is the
choice to eliminate such lesions.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that their
names and initials will not be published and due efforts
will be made to conceal their identity, but anonymity
cannot be guaranteed.
Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 3  ¦  March 2019
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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