Laser Treatment of an Oral Papilloma in the Pediatric Dental Office: a Case Report Juan R

Boj.qxd 3/16/07 3:04 PM Page 307

QUINTESSENCE INTERNATIONAL

Laser treatment of an oral papilloma in the pediatric dental office: A case report Juan R. Boj, DDS, PhD1/Miguel Hernandez, DDS, Phd2/ Enrique Espasa, DDS, PhD2/Clervie Poirier, DDS, PhD3

Squamous cell papilloma is a benign proliferation of the stratified squamous epithelium. It is typically an exophytic lesion smaller than 1 cm. Its appearance varies from cauliflower- like to fingerlike, while the base may be pedunculated or sessile. This article describes the case of an 11-year-old girl who presented with an asymptomatic whitish lesion of papillo- matous appearance in the oral mucosa distal to the maxillary left permanent first molar. The lesion was removed using an Er,Cr:YSGG laser. For anesthesia, 10 mg of 2% lido- caine with epinephrine 1:100,000 was infiltrated around the lesion. No pain medication was required after surgery, and wound healing was excellent and rapidly achieved. The oral pathology report confirmed the presurgical clinical diagnosis. Laser dentistry is a modern technology that can be used by dental clinicians to treat these kinds of oral lesions and should be considered as an alternative to conventional surgery. (Quintessence Int 2007;38:307–312)

Key words: laser dentistry, laser technology, modern dentistry, oral papilloma, pediatric dentistry, squamous cell papilloma

The oral cavity is covered by a membrane of nomas; if the lesion is small and has yet to stratified squamous epithelium, which serves produce metastases when detected, these to cover the oral soft tissue and act as a bar- carcinomas have a 5-year survival rate of rier against external pathogenic agents.1 75%.3 Although the oral mucosa is exposed Because it is exposed to several types of car- to various carcinogens, only a small percent- cinogenic agents from food and the environ- age of people develop cancer.4 However, it ment, this epithelium is prone to the develop- should be remembered that carcinogenesis ment of cancer.2 is a multifactor process, and mutagenesis is Neoplasms of the mouth and pharynx also determined by agents such as the account for 5% of all malignant neoplasms, human papilloma virus (HPV).1–5 and of these 95% are squamous cell carci- HPV is a member of the papovavirus fam- ily, which includes double-strand viruses with a spherical virion 50 nm in diameter.6 To

1Chairman, Department of Pediatric Dentistry, Dental School, date, more than 100 different subtypes of University of Barcelona, Barcelona, Spain. HPV have been identified, of which approxi-

2Professor, Department of Pediatric Dentistry, Dental School, mately 24 specifically infect the oral and gen- University of Barcelona, Barcelona, Spain. ital mucosa. 3Associate Professor, Department of Pediatric Dentistry, Dental The low-risk types of HPV are found on School, University of Barcelona, Barcelona, Spain. the skin and in the mucosa and may cause Reprint requests: Prof Juan R. Boj, Dental School, University of benign lesions such as papillomas, common Barcelona, Campus Ciudad Sanitaria Bellvitge, c.Feixa Llarga s/n, 08097 Hospitalet de Llobregat, Barcelona, Spain. Fax: 34 93 warts, condyloma acuminatum, and focal 2014555. E-mail: [email protected] epithelial hyperplasia. The most frequent

VOLUME 38 • NUMBER 4 • APRIL 2007 307 Boj.qxd 3/16/07 3:04 PM Page 308

QUINTESSENCE INTERNATIONAL Boj et al

subtypes found in the oral cavity are HPV6 Differential diagnosis must be made with and HPV11 in papilloma and condyloma respect to other oral forms of HPV infection acuminatum; HPV2 and HPV4 in common such as common warts, condyloma acumi- warts; HPV13 and HPV32 in focal epithelial natum, and focal epithelial hyperplasia.14 hyperplasia; and HPV6, HPV11, and HPV16 Common warts are often found on chil- in inverted ductal papilloma.6,7 dren’s hands until the second decade of life, HPVs are human pathogens that cause a and the virus contained in the epithelial cells wide range of benign, premalignant, and may propagate by autoinoculation; in this malignant tumors of epithelial origin. Mucous way the lesions spread from the fingers to HPVs are more likely to be sexually transmit- other areas, especially the lips, the hard ted and are considered to be one of the palate, and gingiva. Clinically, common warts world’s most common sexually transmitted are indistinguishable from oral squamous diseases.8 The HPV is tropic for epithelial cell papilloma.14 cells and is found in normal oral mucosa, Condyloma acuminatum usually appears while HPV infection has been reported to be during the second decade of life on the gen- present in 42% of patients with epidermoid itals, although it is also a common feature of (or squamous cell) carcinoma.9 oral lesions when there has been orogenital Squamous cell papilloma is a benign pro- sexual contact or autoinoculation via genital liferation of the stratified squamous epitheli- lesions. Oral lesions mainly occur in the um. It is typically an exophytic lesion that nonkeratinized mucosa of the lips, the jugal measures less than 1 cm in diameter; its mucosa, and the soft palate.6,12,14 appearance varies from cauliflower-like to fin- Focal epithelial hyperplasia, commonly ger-like, while the base may be pedunculated known as Heck disease, is mainly found or sessile. It is the most common of benign among isolated groups of native Indians from neoplasms of the oral epithelium and may North and Central America, Brazil, native appear anywhere in the mouth, although the Nordic peoples, and other groups in Europe most frequent locations are the posterior part and Africa, and is most likely to appear in of the soft palate, the uvula, and the pharyn- children. The lesions are usually multiple, geal pillars. Fine hairy projections are often affect the jugal and labial mucosae, and are observed, and the neoplasm is usually sessile and whitish in color. They are caused whitish in color if the surface is keratinized, by HPV subtypes 13 and 32, and usually dis- although flatter lesions and those with a appear spontaneously in children.14–16 wider base may be reddish or have the pink Controversy remains as to the viral trans- color of normal oral mucosa.6,10,11 It usually mission pathways in children, although the occurs as a single lesion and may appear at possibilities include perinatal transmission, any age; although it is most commonly auto- and heteroinoculation, sexual abuse, observed during the fourth decade, 20% of and, possibly, indirect transmission via cases occur prior to the age of 20 years.12 fomites.17 Histologic features include hyperkera- A study by Summersgill et al reported the tinized hyperplasia of the stratified squa- high-risk subtypes 16 and 18 in 56.2% of mous epithelium, which appears as a prolif- HPV-positive children; moreover, 66% of chil- eration of fine, fingerlike epithelial projections dren infected by the oncogenic subtypes showing hyperkeratosis and a marked layer were younger than 7 years of age.18 of granular cells that extend toward the sur- Kui et al19 studied the clinicopathologic face of the mucosa and that, in their central features of oral condylomas in children and part, contain a fine layer of vascular connec- the condylomatous lesions in their mothers. tive tissue. Reports describe the appearance The study found that 70% of mothers had of both mitotic cells in the spinous layer and suffered oral and/or vulvar condylomatosis a variable number of superficial epithelial during pregnancy and that the oral lesions in cells with pyknotic nuclei and perinuclear children appeared during the first 3 years of clear spaces (koilocytes), indicative of HPV life, the most common site being the palate infection.2,6,7,13 (both hard and soft).

308 VOLUME 38 • NUMBER 4 • APRIL 2007 Boj.qxd 3/16/07 3:04 PM Page 309

QUINTESSENCE INTERNATIONAL Boj et al

Manifestations due to HPV infection are revealed the presence of a whitish tumor on also common among children infected by the the mucosa, distal to the maxillary left per- human immunodeficiency virus (HIV). manent first molar, which had a papilloma- According to the World Health Organization tous appearance and was totally asympto- (WHO) classification,20 HPV infections appear matic (Fig 1). The patient and her family were in group 2 pediatric HIV-positive patients, that unaware of its presence. It was decided to is to say, the group of lesions less often asso- treat the lesion using an Er,Cr:YSGG laser ciated with pediatric HIV infection. (Biolase Technology) instead of removing the Finally, recipients of organ transplants are lesion with conventional surgery. another group of immunosuppressed patients A 20% benzocaine gel was applied as top- with an increased risk of HPV-related oral ical anesthesia before injecting 10 mg of 2% mucosa lesions. Oral warts and papillomas lidocaine with epinephrine 1:100,000 around have been reported in bone marrow recipients the lesion; the lesion itself was not infiltrated. between 1 and 3 years after the transplant.21,22 Then, using the low power recommended by The treatment of squamous papilloma the manufacturer for soft tissue (1.50 W, 10% consists of the simple surgical removal of the water, and 11% air), a circular incision was base of the lesion and a small area of the sur- made around the lesion to be able to obtain rounding connective tissue. Relapses are a valid sample for biopsy (Fig 2). rare.1 The use of laser as a surgical method The design of the handpiece of the laser for removing oral papillomas has also been equipment offered good control and access described.23–25 to the mucosa distal to the molar; in such The term laser is an acronym for “light cases, this reduces operative time, makes amplification by stimulated emission of radia- the surgical technique easier, and provides tion,” this being a kind of electromagnetic better handling of the surgical field, all of energy with directional and monochromatic which leads to better tissue care. During properties that distinguish it from disorgan- laser irradiation slight impacts were made ized radiant energy. The Er,Cr:YSGG on the distal part of the molar, and this pro- (erbium, chromium, yttrium, scandium, galli- duced small areas of demineralization. um, and garnet) laser is one of the most fre- Once the lesion was removed, coagulation quently used by pediatric dentists because was achieved using the laser at low wattage of its versatility: It can be used in both hard (0.50 W) and with 0% water and 7% air and soft tissues and is associated with a (Fig 3). reduction in postoperative discomfort, Postoperative healing was excellent and edema, scarring, and shrinkage.26,27 no pain medication was required, the wound The successful use of laser technology has healing perfectly in a short period of time (Fig been reported for restorative procedures in 4). The 6-month follow-up examination (Fig primary and permanent teeth, for pulpal treat- 5) showed remineralization of the enamel of ments, and for different surgical or oral pathol- the first molar where it was impacted by the ogy treatments.26–33 There is no need for local laser. anesthesia in some treatments, and in many The oral pathology report showed, at the others a smaller amount is required than macroscopic level, a small, soft fragment when using conventional techniques.34–36 (0.25 cm in size) of papillomatous appear- ance with a whitish outer surface (Fig 6). Microscopic examination revealed tissue covered by keratinizing stratified squamous CASE REPORT epithelium with marked hyper- and paraker- atosis. Also observed were superficial epithe- The patient, aged 11 years and 11 months lial cells with pyknotic nuclei and perinuclear with no pathologic history of note, had excel- clear spaces, this being indicative of HPV lent oral hygiene and was seen for a routine infection. The underlying chorion showed checkup 15 months after her previous visit. dilated vascular spaces and chronic inflam- Routine examination of the oral cavity matory changes.

VOLUME 38 • NUMBER 4 • APRIL 2007 309 Boj.qxd 3/16/07 3:04 PM Page 310

QUINTESSENCE INTERNATIONAL Boj et al

Fig 1 Preoperative view of the lesion. Fig 2 Circular incision around the lesion at the start of surgery with the aim of resecting a sample for biopsy.

Fig 3 Immediate postoperative view. The molar Fig 4 Three-week postoperative view. shows some small areas of demineralization due to the impact of the laser while the surgery was per- formed.

Fig 5 Six-month postoperative view. Reminerali- Fig 6 Biopsy specimen. zation has occurred on the affected areas of the molar.

310 VOLUME 38 • NUMBER 4 • APRIL 2007 Boj.qxd 3/16/07 3:04 PM Page 311

QUINTESSENCE INTERNATIONAL Boj et al

DISCUSSION REFERENCES

This article has described the use of an 1. Sapp JP,Eversole LR,Wysocki GP.Contemporary Oral Er,Cr:YSGG laser to treat a patient presenting and Maxillofacial Pathology, ed 2. Philadelphia: Mosby, 2004:165–166. with a papillomatous lesion. This is a hydro- 2. Tinoco J, Furtado da Silva A, Basilio de Oliveira C, kinetic system that liberates photons in an Rapoport A, Fava A, Pires de Souza R. Human papil- air-water spray, thus causing powerful explo- lomavirus (HPV) infection and its relation with sions in the water drops. The energy of the squamous cell carcinoma of the mouth and laser is carried by an optical fiber system to a oropharynx. Rev Assoc Med Bras 2004;50:252–256. terminal point of sapphire crystal. The laser 3. Syrjänen S. Human papillomavirus infections and handpiece is similar to the classic high- oral tumors. Med Microbiol Immunol 2003;192: 123–128. speed handpiece, thus making it easier for 4. Alaram P, Nalinakumari K, Abraham E, et al. Human the clinician to use. Cutting effectiveness papillomaviruses in 91 oral cancers from Indian reaches 1.0 to 1.5 mm from the sapphire betel quid chewers—High prevalence and multi- point to the surface of the tissue. plicity of infections. Int J Cancer 1995;61:450–454. This laser is excellent for surgical oral 5. Scully C. Oral squamous cell carcinoma: From a treatments in pediatric patients because it is hypothesis about a virus, to concern about possible associated with less need for local anesthe- sexual transmission. Oral Oncol 2002;38:227–234. sia, reduced surgical time, easier technique, 6. Sapp JP,Eversole LR,Wysocki GP.Contemporary Oral and Maxillofacial Pathology, ed 2. Philadelphia: a hemostatic effect with no bleeding, and Mosby, 2004:223–226. perfect visibility of the surgical field. 7. Haberland-Carrodeguas C, Fornatora M, Reich R, Furthermore, there is no need for suturing, Freedman P. Detection of human papillomavirus and neither edema nor postoperative pain DNA in oral inverted ductal papillomas.J Clin Pathol results from the procedure; wounds heal 2003;56:910–913. quickly without discomfort or the need for 8. Bruce A, Rogers R. Oral manifestations of sexually analgesic medication. In the present case a transmitted diseases. Clin Dermatol 2004;22: 520–527. minimal amount of local anesthetic was 9. Ibieta B,Lizano M,Fras-Mendivil M,Barrera J,Carrillo used, and the postoperative healing was A, Mohar A. Human papilloma virus in oral squa- highly satisfactory. mous cell carcinoma in a Mexican population. Oral During laser treatments, the lesion itself Surg Oral Med Oral Pathol Oral Radiol Endod 2005; is sometimes “lasered,” which prevents a 99:311–315. biopsy of the surgical sample from being 10. Severson J,Evans TY,Lee P,Chan T,Arany I,Tyring SK. performed. This was not the case with our Human papillomavirus infections: Epidemiology, pathogenesis and therapy. J Cutan Med Surg 2001; patient because the lesion did not receive 5:43–60. the impact of the laser, and the subsequent 11. Laskaris G. Color Atlas of Oral Diseases, ed 3. New biopsy confirmed the presumed diagnosis of York:Thieme, 2003:366–367. a lesion caused by the human papilloma 12. McDonald R, Avery D, Dean J.Dentistry for the Child virus. and Adolescent, ed 8. Philadelphia: Mosby, 2004: The fact that some treatments can be per- 150–151. formed without local anesthesia is a further 13. Laskaris G, Scully C. Periodontal Manifestations of advantage that facilitates behavioral manage- Local and Systemic Diseases: Colour Atlas and Text. New York: Springer, 2003:103–105. ment by the pediatric dentist. Laser equip- 14. Pinkham J, Casamassimo P, Fields H, McTigue D, ment offers the clinician a wider variety of Nowak A. Pediatric Dentistry: Infancy through tools that benefit the whole pediatric dental Adolescence, ed 4. Philadelphia: Elsevier, 2005:34. population and contribute to the improve- 15. Teo CG. Viral infections in the mouth. Oral Dis ment of pediatric dental treatments. 2002;8(suppl 2):88–90. 16. Bassioukas K, Danielides V, Georgiou I. Oral focal epithelial hyperplasia. Eur J Dermatol 2000;10: 395–397. 17. Syrjanen S, Puranen M. Human papillomavirus infections in children:The potential role of maternal transmission. Crit Rev Oral Biol Med 2000;11: 259–274.

VOLUME 38 • NUMBER 4 • APRIL 2007 311 Boj.qxd 3/16/07 3:04 PM Page 312

QUINTESSENCE INTERNATIONAL Boj et al

18. Summersgill K, Smith E, Levy B, Allen J, Haugen T, 26. Boj J, Galofre N, España A, Espasa E. Pain perception Turek L. Human papillomavirus in the oral cavities in pediatric patients undergoing laser treatments. J of children and adolescents. Oral Surg Oral Med Oral Laser Appl 2005;5:85–89. Oral Pathol Oral Radiol Endod 2001;91:62–69. 27. Boj JR. The future of laser pediatric dentistry. J Oral 19. Kui L, Xiu H, Ning L. Condyloma acuminatum and Laser Appl 2005;5:173–177. human papilloma virus infection in the oral mucosa 28. Gontijo I,Navarro R,Haypek P,Ciamponi AL,Haddad of children. Pediatr Dent 2003;25:149–153. AE. The applications of diode and Er:YAG lasers in 20. Classification and diagnostic criteria for oral lesions labial frenectomy in infant patients. J Dent Child in HIV infection. EC-Clearinghouse on Oral 2005;72:10–15. Problems Related to HIV Infection and WHO 29. Martens LC. Laser assisted pediatric dentistry: Collaborating Centre on Oral Manifestations of the Review and outlook. J Oral Laser Appl 2003;3: Immunodeficiency Virus. J Oral Pathol Med 1993; 203–209. 22:289–291. 30. Stabholz A, Zeltser R, Sela M, Peretz B, Moshonov J, 21. Barasch A, Safford N, Catalanotto F. Oral soft tissue Zisking D.The use of lasers in dentistry:Principles of manifestations in HIV-positive vs. HIV-negative chil- preparation and clinical applications. Compend dren from an inner city population: A two-year Contin Educ Dent 2003;24:935–948. observational study. Pediatr Dent 2000;22:215–220. 31. Diedrich D,Bushick R.Lasers in dentistry:Separating 22. Schubert M. Oral manifestations of viral infections science from hype. J Am Dent Assoc 2004;135: in immunocompromised patients. Curr Opin Dent 204–210. 1991;1:384–397. 32. Parkins F. Lasers in pediatric and adolescent den- 23. Persky MS. Carbon dioxide laser treatment of oral tistry. Dent Clin North Am 2000;44:821–830. florid papillomatosis. J Dermatol Surg Oncol 1984; 33. Kotlow LA. Lasers in pediatric dentistry. Dent Clin 10:64–66. North Am 2004;48:889–922. 24. White J, Chaudry S, Kudler J, Sekandari N, Schoelch 34. Jacobson B, Berger J, Kravitz R, Patel P. Laser pedi- M, Silverman S. Nd: YAG and CO2 laser therapy of atric crowns performed without anesthesia: A con- oral mucosal lesions. J Clin Laser Med Surg 1998; temporary technique. J Clin Pediatr Dent 2003;28: 16:299–304. 11–12. 25. Akyol A, Anadolu R, Anadolu Y,Ekmekci P,Gürgey E, 35. Jacobson B, Berger J, Kravitz R, Ko J. Laser pediatric Akay N. Multifocal papillomavirus epithelial hyper- class II composite utilizing no anesthesia. J Clin plasia: Successful treatment with CO2 laser therapy Pediatr Dent 2004;28:99–102. combined with interferon alpha-2b. Int J Dermatol 36. Boj JR, Poirier C, Espasa E, Hernandez M, Jacobson B. 2003;42:733–734. Eruption cyst treated with a laser powered hydroki- netic system. J Clin Pediatr Dent 2006;30:199–202.

312 VOLUME 38 • NUMBER 4 • APRIL 2007