Keywords
oral cavity - papilloma - torus - palatal - human papilloma virus
Introduction
Oral Verruca Vulgaris
Verruca vulgaris is typically seen on hands, feet, toes, and fingers.[1] The occurrence of verruca vulgaris intraorally is less common compared to oral squamous
papilloma.[2]
Although OVV rarely shows malignant change, it could be transmitted to other sites
if left untreated.[3] The mode of transmission of the human papilloma virus (HPV) could be from autoinoculation,
oral sex, or vertically from pregnant mother to child.[4]
[5]
[6]
Torus Palatinus
Torus palatinus is the bone prominence or the exostosis situated in the median palatine
region of the maxilla; it has a high prevalence in Asian and Mongoloid ethnic groups.[7] The lack of vascularity and thin mucosal covering of the tori increases the likelihood
of traumatic ulcers and inflammation around the exostosis.[8] The surgical removal of torus palatinus is usually indicated before fitting maxillary
dentures or when there is a traumatic ulcer. In some severe instances, ulcers may
expose the torus by perforating the mucosa causing dysphagia and halitosis.[9]
Case Report
A 48-year-old male patient complained of a whitish growth on his palate. He noticed
the lesion approximately 2 months before seeking advice from his dentist. The patient
was a smoker averaging 10 cigarettes per day, with occasional alcohol intake. Intraoral
examination revealed a whitish lesion confined to the middle of a torus palatinus.
The lesion was asymptomatic and was not tender on palpation ([Fig. 1]).
Fig. 1 (A) Palatal torus with white lesion from the mirror photographic. (B) Direct photographic of the whole maxillary arch showing moderate sized torus palatinus.
Surgical Procedure
An excisional biopsy was done concomitant with torectomy. The surgical wound was sutured
without the use of a splint. Overall 14 days after surgery, the site had healed uneventfully.
A follow-up at 6 months revealed no recurrence ([Fig. 2]). The soft tissue sends to the pathological department for biopsy report.
Fig. 2 Healing after 14 days postexcisional biopsy and torectomy.
Biopsy Result
[Fig. 3A] and [B] showed under the microscope; acanthosis is seen with marked hyperkeratosis with
bacterial colonies on the surface. Hypergranulosis is seen with coarse keratohyalin
granules. Koilocytic change and intracellular bodies are seen. These findings are
suggestive of OVV.
Fig. 3 (A) Acanthosis with marked hyperkeratosis and bacterial colonies on the surface. (B) Hypergranulosis is seen with coarse keratohyalin granules.
Discussion
The palatal torus is quite common in Southeast Asia; the removal of it is done to
help fit dentures that cover the palatal region to prevent discomfort. The thin mucosa
covering the palatal torus makes it prone to get ulcerations, which could expose the
palatal mucosa to pathogens.[9] The constant trauma to epithelium could potentially be the source of entry of HPV
into the basal keratinocytes.
Nonetheless, the histopathological diagnosis of verruca vulgaris is distinctive and
enough to differentiate this lesion from other white mucosal lesions in the oral cavity
such as frictional keratosis. The presence of intracellular bodies and hypergranulosis,
which we see in our case report is not usually seen in frictional keratosis or traumatic
keratosis according to Abidullah et al[10] and Sudhakar et al.[11]
In this case, the lesion was hyperkeratotic and nonscrapable, which ruled out the
presence of candida infection. To the best of this author’s knowledge and based on
a thorough online search of previously published articles on OVV, we are the first
to document OVV on a palatal torus. This finding is however not entirely surprising
because palatal tori are very easily traumatized
The strain of HPV involved in the pathogenesis of OVV is usually HPV type 2 and HPV
type 4.[3] These have a low potential for malignant change.[12] Nonetheless, to ascertain the specific type of HPV infection, a polymerase chain
reaction assay is necessary. Genital warts or condyloma acuminatum have been shown
to carry multiple strains of HPV (both low and high-risk types).[13] With the rising trend of oral sexual practice, reports of HPV infection from genital
to oral regions are expected to rise accordingly.[14]
Although rare, Atullah et al documented a case of OVV on the lip which transformed
into oral squamous cell carcinoma in 4 years when left untreated.[15] Verruca vulgaris on extraoral regions such as the eyelid have also been reported
with malignant change into a combination of squamous cell carcinoma and basal cell
carcinoma.[16]
The benign nature of OVV should not be taken for granted, prompt excisional biopsies
are warranted to prevent any potential for malignant change. In this case, concomitant
torectomy was done to reduce recurrence, this is based on the belief that trauma to
the torus was how HPV inoculated the overlying palatal mucosa.
