Case #11

A 15-year-old female visited a general dentist for an annual check-up. Extraoral examination revealed a cluster of growths on the skin near the right commissure.

Nov 1st, 1996

A 15-year-old female visited a general dentist for an annual check-up. Extraoral examination revealed a cluster of growths on the skin near the right commissure.

Joen Iannucci Haring, DDS, MS

History

The patient was aware of the lesions on her facial skin and stated that the growths had been present for approximately one month. The patient denied any pain or symptoms associated with the lesions. When questioned about her last medical visit, the patient stated that she was seen by a physician several months earlier for the treatment of strep throat.

The patient appeared to be in a general good state of health with no significant medical history. The patient`s dental history included regular examinations and routine dental treatment. At the time of the dental appointment, the patient was not taking medications of any kind.

Examinations

Intraoral examination revealed no significant positive findings. Extraoral examination of the head and neck region revealed a cluster of papillary growths on the skin of the face adjacent to, but not involving, the right commissure of the lips (see related photograph). No enlarged lymph nodes were detected upon palpation. No other lesions were noted during the extraoral examination.

Clinical diagnosis

Based on the clinical information available, which of the following is the most likely diagnosis?

- verruca vulgaris

- angular cheilitis

- acne vulgaris

- seborrheic keratosis

- keratoacanthoma

Diagnosis

_ verruca vulgaris

Discussion

Verruca vulgaris, the common wart (vulgaris meaning common, verruca meaning wart), is caused by the human papilloma virus. Verruca vulgaris is a benign lesion that affects both the skin and oral cavity; the skin is affected far more frequently than oral tissues. This viral lesion is contagious and easily spread from one area to another by scratching or rubbing. Infection often results by way of autoinoculation.

Clinical features

Warts are seen in approximately 10 percent of the population. Verruca vulgaris is frequently identified in children, although adults can be affected as well. There is no sex predilection. When skin is involved, the fingers and hands are the most common locations.

When the oral tissues are affected, likely locations include the vermilion of the lip, labial mucosa, and anterior tongue. Verruca vulgaris may present as a single lesion or, more commonly, in clustered multiples. The typical common wart is asymptomatic.

Verruca vulgaris has a variety of clinical appearances. It may exhibit numerous "fronds" or small, fine finger-like projections that are clumped together, or, it may appear as a nodule with papillary projections and a rough verruciform (warty) surface. The lesion may be sessile or pedunculated. The color of the verruca vulgaris varies depending upon location. The skin lesions appear white, yellow, or pink, while the intraoral lesions appear white. The common wart grows rapidly and reaches a maximum size of approximately 5 millimeters in diameter.

Diagnosis

Although the common wart has a suggestive clinical appearance, it closely resembles the squamous papilloma (RDH, June 1991) as well as the condyloma accuminatum (sexually transmitted wart). In order to differentiate between these three lesions, a biopsy and histologic examination is necessary.

Treatment

It is important to reassure the dental patient that the common wart is a benign lesion with no malignant potential. Common warts of the skin are treated by conservative surgical excision, curettage or cryotherapy with liquid nitrogen. Oral lesions are usually excised surgically, although cryotherapy can also be used.

Verruca vulgaris may recur if the lesion is incompletely removed. In many instances, multiple treatments may be required.

If the common wart is left untreated, some lesions may regress spontaneously. Two-thirds of untreated warts disappear within 2 years.

Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.

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