Condyloma Acuminatum
Quick Summary Introduction References Photos		Clinical Features Histopathology Treatment Prognosis
Blunted surface papules with koilocytes in the epithelium.

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Introduction

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Yet another papilloma look-alike lesion is the HPV-induced condyloma acuminatum (condyloma = "knuckle or knob"), an epithelial proliferation considered to be a sexually transmitted disease (STD). The condyloma develops at a site of sexual contact or trauma and is, therefore, much more common in the anogenital region, where it represents approximately 20% of all STDs. Not surprising, the virus involved with oral condyloma acuminatum is HPV, especially subtypes HPV-6, HPV-11, HPV-16, and HPV-18. The later two subtypes are among those associated with carcinoma and epithelial dysplasia of genital mucosa, perhaps explaining why the condyloma is considered a premalignant lesion by many. For reasons unknown, this precancerous character does not seem to be a part of condylomas arising from oral and oropharyngeal mucosa.

It is not unusual for a patient with a condyloma to have multiple STDs and so caution is advised relative to infection control procedures in the dental office. This multi-disease feature is so strong, in fact, that the genital condyloma was once thought to be a characteristic feature of syphilis rather than a separate entity. The condyloma is very contagious and may spread by auto-inoculation to other sites of trauma.

Clinical Features

Condyloma usually is diagnosed in teenagers and young adults, but all ages are susceptible. Oral lesions occur most frequently on the lip mucosa, the lingual frenum and the soft palate, all points of potential trauma during cunnilingus and fellatio. The lesion presents as a broad-based, pink mass with the surface covered by short, blunted projections, giving it a raspberry or mulberry appearance (Figures 1& 2). Many lesions have a mild semi-transparency to the surface nodules. Condylomata tend to be larger than papillomas and are characteristically multiple and clustered. The average lesional size is 1.0-1.5 cm., but lesions as large as 3 cm. have been reported. Even large oral condylomata are seldom elevated more than a few millimeters above the surface.

Pathology and Differential Diagnosis

 Condyloma acuminatum presents as a benign proliferation of acanthotic stratified squamous epithelium with mildly keratotic papular or nodular surface projections. Thin connective tissue cores support the papillary epithelial projections, which are more blunted and broad than those of squamous papilloma and verruca vulgaris (Figures 3 & 4). The appearance of keratin-filled crypts between prominences of the latter disease are seldom found in the condyloma.

The covering epithelium is mature and differentiated, but superficial keratinocytes commonly contain pyknotic nuclei surrounded by clear zones (koilocytes), a classical microscopic feature of HPV infections. Ultrastructural examination will reveal virions within the cytoplasm and/or nuclei of koilocytes and the virus also can be demonstrated by immunohistochemistry, in situ hybridization and polymerase chain reaction techniques. The diagnosis, however, seldom requires the use of special methods. The reader is referred to the pathology section of the discussion of the squamous papilloma for a review of the differential diagnosis of oral papillary lesions with similarities to condyloma.

Treatment and Prognosis

Condyloma is treated by conservative surgical excision, topical application of podophyllin, or laser ablation. The latter treatment has raised some question as to the airborne spread of HPV through the aerosolized microdroplets created by the vaporization of lesional tissue. Regardless of the method used, a condyloma should be removed because it is contagious and capable of spreading to other oral surfaces as well as to other persons through direct, usually sexual, contact.

In the anogenital area, this lesion may demonstrate a premalignant character, especially when infected with HPV subtypes 16 and 18, but this has not been demonstrated in oral lesions. It should be remembered that condyloma may be an oral manifestation of a greater problem, such as child sexual abuse or HIV infection.

References (Chronologic Order)

Note: Click on underlined author's names for additional detail.

General references:

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. Philadelphia, W. B. Saunders; 1995.

Elder D, Elenitsas R, Jaworsky C, Johnson B Jr. Lever's Histopathology of the skin, 8th edition. Philadelphia; Lippincott-Raven, 1997.

Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. Mosby; St. Louis, 1997.

Odell EW, Morgan PR. Biopsy pathology of the oral tissues. London; Chapman & hall Medical, 1998.

Specific references:

Simon PA. Oral condyloma acuminatum as an indicator of sexual abuse: dentistry's role. Quintessence Int 1998; 29:455-458.

Pictures

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