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

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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.
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