Oral Verruca Vulgaris: Symptoms, Diagnosis, and Treatment

Introduction

Verruca vulgaris (VV), commonly known as the benign wart or viral wart in medical literature and research, is recognized as a virus-induced tumor or neoplasm that affects the skin. Oral verruca vulgaris (OVV) manifests as distinct white warts on the tongue's surface. The article discusses the clinical characteristics of OVV, its diagnosis, and oral management.

What Is Oral Verruca Vulgaris (OVV)?

Oral verruca vulgaris (OVV) is a condition primarily attributed to the human papillomavirus (HPV). It is characterized by the presence of viral-origin warts, typically found on the body. In the case of OVV, these warts specifically develop on the tongue. When verruca vulgaris manifests within the oral cavity, it is referred to as OVV, and the tongue is the most common location for these lesions.

Clinically, OVV lesions are described as sessile and well-defined growths. They protrude from the surface of the tongue and exhibit a papillomatous texture. The OVV can affect individuals of any age, with no significant gender predisposition. However, there have been reported cases of higher incidence rates in children, and OVV may occasionally manifest on the vermilion border of the lips or other oral mucous membranes besides the tongue. Given the prevalence of OVV lesions on the tongue, it is essential to understand the clinical condition in detail.

Are the Oral Verruca Vulgaris (OVV) Lesions Asymptomatic?

• OVV lesions on the tongue are described as having a fleshy, irregular, or pebbly surface with a distinctive white color.

• These lesions may have finger-like projections extending to the tongue's borders and can gradually increase in size if left untreated.

• The OVV lesions do not cause pain or pus discharge, which can lead some patients to overlook them.

• OVV can also manifest similar lesions on the skin due to the human papillomavirus (HPV) affecting superficial epithelial cells.

• Dentists should look for nodules or plaque-like formations on moist skin areas, like leg tendons.

• Verruca Vulgaris, often linked with children, can affect younger adults and middle-aged individuals as well.

• Oral and extra-oral verruca vulgaris lesions appear as painless, papular, or nodular projections with a rough, pebbly surface.

• Extra-oral lesions may have pink, yellow, or white appearance, while oral lesions consistently appear white.

• The rate of enlargement of these lesions can vary; some grow rapidly, while others remain stable for months or years.

• Irritation can lead to the emergence of multiple or clustered lesions, causing clinical inflammation and further spread.

How to Diagnose Oral Verruca Vulgaris Lesions (OVV)?

Detecting the presence of human papillomavirus (HPV) in the oral cavity and correlating it with the clinical exophytic lesions allows for a confirmative diagnosis. Oral pathologists and oral and maxillofacial surgeons/dentists employ various diagnostic methods for this purpose:

• Electron Microscopy: A high-resolution imaging method for studying cellular structures and viral particles, useful for visualizing HPV in OVV.

• Immunohistochemistry: It is a technique that uses antibodies to detect specific proteins in tissues, helping identify HPV-related markers in OVV diagnosis.

• Polymerase Chain Reaction (PCR): It is a technique used to make numerous copies of specific segments and find DNA or RNA of the disease-causing pathogen.

• DNA Sequencing: This technique is employed for analyzing genetic material and identifying variations in DNA, allowing for precise HPV detection in OVV.

What Is the Differential Diagnosis of Oral Verruca Vulgaris (OVV)?

Given that many oral lesions share similarities with both benign and malignant tumors, the dentist or oral surgeon needs to differentiate them from one another before confirming the diagnosis of OVV. Following are some conditions to consider in the differential diagnosis of OVV lesions (distinct from other HPV-related oral lesions):

• Squamous papilloma (benign overgrowth of soft tissue associated with human papillomavirus).

• Condyloma acuminatum (a sexually transmitted disease causing papillomatous growth in the genitalia).

• Keratoacanthoma (it is a low-graded, rapidly growing skin tumor).

• Exophytic verrucous carcinoma (a subtype of squamous cell carcinoma, causing exophytic or cauliflower-like overgrowth of tissues).

• Focal epithelial hyperplasia (rare, benign disease of oral mucosa caused by human papillomavirus).

• Exophytic squamous cell carcinoma (it is an uncommon variant of squamous cell carcinoma affecting the upper aerodigestive tract mucosa).

• Verruciform xanthoma (benign proliferative lesion causing cauliflower-like overgrowth of tissues).

What Are the Histopathological Features of Oral Verruca Vulgaris (OVV)?

On histopathological examination, verruca vulgaris lesions exhibit distinct characteristics:

• These lesions are characterized by hyperkeratotic proliferation of stratified squamous epithelial cells arranged in finger-like projections.

• They possess a typical connective tissue core with chronic inflammatory cells infiltrating the surrounding connective tissues.

• Rete ridges are present, producing a cupping effect, and coarse, clumped keratohyalin granules are evident.

• These lesions are commonly observed on the vermilion border, labial mucosa, and tongue within the oral mucosa.

• Koilocytes, which are distinctive cells, are indicative of OVV and can be found in approximately 89 percent of examined oral verrucae.

How to Manage Oral Verruca Vulgaris (OVV)?

The primary treatment approach for OVV, primarily affecting the tongue, involves surgical resection performed by oral and maxillofacial surgeons under local anesthesia. During this procedure, hemostasis, often accomplished through cauterization, is a critical focus. Following the resection, the surgical wound is thoroughly irrigated and closed with sutures. Patients may also receive routine antibiotic prophylaxis for a speedy recovery.

For mild to moderate OVV lesions, the following alternative treatment methods can be considered:

• Retinoid Therapies: Retinoids, derived from vitamin A, have the potential to stop the growth of lesions, or wart cells. When retinoid medications prove ineffective, interferon-alfa medications are administered directly into lesions, or warts may be preferred.

• Salicylic Acid: Topical treatment using 17 percent salicylic acid, available in patch form, can be used to treat OVV lesions.

• Cantharidin: Some surgeons use cantharidin as a promising substance for treating warts or lesions. Also, cryotherapy or liquid nitrogen therapy effectively destroys verrucous warts or lesions by freezing them, though it may require multiple rounds of treatment.

• Laser Surgery: Despite its cost and the potential for post-operative scarring, laser surgery is known for its effectiveness in treating OVV lesions.

• Electrodesiccation: This alternative treatment strategy involves the use of an electric needle for localized tissue destruction and offers a viable option for surgical resection for OVV lesion management.

Conclusion

Oral verruca vulgaris, which mainly affects the tongue, is not very common. These growths look different, can cause problems with speaking and eating, and can make people feel uncomfortable or embarrassed if not treated. To prevent them from spreading and causing more issues, dentists or oral surgeons need to remove them completely. Doctors should also check for similar growths on the skin, as this can improve the patient's life and chances of getting better.