What is the management of an oral lesion associated with Human Papillomavirus (HPV)?

Management of HPV-Associated Oral Lesions

Surgical excision is the recommended treatment for HPV-related oral lesions including squamous papilloma, condyloma acuminatum, verruca vulgaris, and multifocal epithelial hyperplasia, because a small percentage can harbor dysplasia and progress to malignancy, particularly in immunosuppressed patients. 1

Benign HPV Oral Lesions: Clinical Recognition

The primary HPV-associated oral lesions you'll encounter include:

• Squamous papilloma (most common, ~94% of cases): Exophytic, sessile or pedunculated growths with papillary projections, appearing pink or white depending on keratinization; caused by low-risk HPV types 6 and 11 in approximately 50% of cases 1, 2

• Condyloma acuminatum: Sessile or pedunculated lesions with papillary projections, more common in adolescents and young adults; caused by low-risk HPV 6 and 11 but may harbor high-risk types 16 and 18 1, 3

• Verruca vulgaris: Well-circumscribed growth with prominent hyperkeratosis giving a white pebbly surface; caused by HPV 2 and 4; occurs via autoinoculation from fingers to mouth 1

• Multifocal epithelial hyperplasia (Heck disease): Multiple small, slightly elevated papules in tight clusters creating a cobblestone appearance; caused by HPV 13 and 32; often spontaneously regresses after months to years 1

Treatment Algorithm

Primary Treatment Approach

Complete surgical excision is the standard of care because:

• Only a few oral squamous papillomas and condylomata can be dysplastic (<1%), but this risk necessitates complete removal 1
• Condylomata with high-risk HPV genotypes carry increased risk for dysplasia and squamous cell carcinoma development, particularly in immunosuppressed individuals 1, 3
• Complete removal of infected epithelium at the base prevents recurrence 1, 3

Alternative Treatment Options for Condyloma Acuminatum

When surgical excision is not feasible or for smaller lesions:

• Cryotherapy: Destroys lesions through thermal-induced cytolysis; effective for smaller lesions 3
• Electrocautery: Single-visit treatment under local anesthesia for visible warts 3
• Topical agents: Podophyllin resin (10-25%) or trichloroacetic acid applied sparingly to warts 3
• Photodynamic therapy: For refractory cases, with clearance rates of 66-95% and lower recurrence rates than conventional treatments 3

Critical Management Considerations

Malignant Transformation Risk

High-risk HPV genotypes (16,18) are associated with dysplasia and squamous cell carcinoma, especially in:

• Immunosuppressed patients 1
• Lesions showing progressive growth or ulceration 4
• Condylomata that may progress from low-grade to high-grade dysplasia 1

Recurrence Prevention

• Recurrence is unusual after proper treatment and typically results from incomplete removal of infected epithelium at the lesion base 1, 3
• New lesions may appear from continued reinfection or transition of subclinical to clinical lesions 1, 3
• Malignant transformation has not been reported in verrucae or multifocal epithelial hyperplasia 1

Follow-Up Protocol

Regular monitoring is essential, particularly for:

• Immunosuppressed patients at higher risk for dysplastic transformation 1
• Any lesion showing persistent growth, ulceration, or change in appearance 4
• Patients with condylomata harboring high-risk HPV types 1, 3

Common Pitfalls to Avoid

• Incomplete excision: Ensure removal of the entire lesion base to prevent recurrence 1, 3
• Assuming all oral papillary lesions are benign: Always consider biopsy for histopathologic confirmation, especially if clinical features are atypical 4
• Missing high-risk HPV association: Condylomata can harbor HPV 16 and 18 despite appearing benign 1, 3
• Inadequate follow-up in immunosuppressed patients: This population has significantly higher risk of dysplastic progression 1