Journal of Indian Society of Periodontology
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Year : 2020  |  Volume : 24  |  Issue : 6  |  Page : 572-574  

Squamous cell papilloma of the gingiva with a “garlanding a tooth” appearance: Report of an unusual case

1 Department of Periodontics and Oral Implantology, Institute of Dental Sciences, Siksha ‘O’ Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
2 Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Siksha ‘O’ Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India

Date of Submission26-Sep-2019
Date of Decision22-Mar-2020
Date of Acceptance14-Apr-2020
Date of Web Publication21-Sep-2020

Correspondence Address:
Dr. Anurag Satpathy
Department of Periodontics and Oral Implantology, Institute of Dental Sciences, Siksha eOf Anusandhan (Deemed to be University), Khandagiri Square, Bhubaneswar - 751 030, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_502_19

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Squamous cell papilloma of the gingiva is a benign, asymptomatic, exophytic nonplaque-associated gingival lesion caused by human papillomavirus. It affects several areas of the oral cavity with a relatively lower predilection for gingiva. The finger-like clinical presentation may be scary, misleading and may be confused with other lesions. This report presents a case of squamous cell papilloma of the gingiva. We report an unusual case of squamous papilloma of the gingiva with an unusual “garlanding a tooth” appearance.

Keywords: Benign, gingiva, human papilloma virus, squamous cell papilloma

How to cite this article:
Datta P, Panda A, Lenka S, Satpathy A. Squamous cell papilloma of the gingiva with a “garlanding a tooth” appearance: Report of an unusual case. J Indian Soc Periodontol 2020;24:572-4

How to cite this URL:
Datta P, Panda A, Lenka S, Satpathy A. Squamous cell papilloma of the gingiva with a “garlanding a tooth” appearance: Report of an unusual case. J Indian Soc Periodontol [serial online] 2020 [cited 2022 Aug 14];24:572-4. Available from:

   Introduction Top

Squamous papilloma is one of the benign lesions of the oral cavity and is the fourth most common lesion of occurrence. Although oral squamous cell papilloma can affect tongue, skin, pharynx, larynx, and lip, its appearance on the gingiva is relatively rare. The etiology of this condition has been attributed to human papillomavirus (HPV), and the lesion progresses due to proliferation of the stratified squamous epithelium.[1] HPV-6, HPV-11, HPV-13, and HPV-32 are the major viruses associated with this lesion.[2],[3] Two types of squamous papilloma have been reported; multiple reoccurring and isolated solitary. Based on the gender, squamous cell papilloma has a higher prediction to occur in males as compared to females. Clinically, it is usually asymptomatic with varied rate of recurrence. A complete excision of the lesion is usually the treatment of choice. We report an unusual case of squamous papilloma of the gingiva with an unusual “garlanding a tooth” appearance around a tooth.

   Case Report Top

A 52-year-old male patient reported to the outpatient department with a chief complaint of growth in the gums in the lower left back tooth region. The lesion was first noticed by the patient 2 years back as a small white lesion on the gingiva, which slowly and progressively enlarged to its present size. There was no history of the presence of a similar lesion elsewhere in the oral cavity or any other part of the body. He had a habit of occasional paan chewing for 7–8 years. His medical and family histories were noncontributory.

On examination, a localized solitary exophytic lesion involving the marginal and attached gingiva was seen on the keratized gingiva of entire facial aspect of the mandibular left second premolar. The lesion presented as a white cauliflower-like growth with tiny finger-like projections [Figure 1]. The size of the lesion was 6 mm × 10 mm: apicocoronally and mesiodistally, respectively [Figure 2]. Overall, a florid growth with wide base circumscribing the entire facial aspect typically gives a lesion a “garlanding a tooth” appearance around the tooth no. 35 clinically. It was nontender, and there was no gingival bleeding or exudation on pressure associated with it.
Figure 1: Clinical view of the lesion

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Figure 2: Extent of the lesion (a) mesio-distally (b) corono-apically

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Intraoral periapical radiograph revealed a slight crestal bone loss in relation to 35 and 36 [Figure 3]. The differential diagnosis included fibroma, epulis, and papilloma. Serological investigations were within normal limits. Test for HIV was negative.
Figure 3: Crestal bone loss in relation to mesial and distal aspect of 35 and 36

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The patient was educated about the lesion and his consent was obtained before the surgical excision procedure. An antiseptic solution was used topically extraorally as well as intraorally at the surgical site. The area was anesthetized with local infiltration with 2% lignocaine solution. The lesion was completely excised with 2 mm of the healthy gingival margin [Figure 4]. A pressure pack was applied to prevent excessive bleeding initially; later, periodontal dressing was placed on the surgical site to cover the exposed surgical wound. The patient did not report back after excision, and the follow-up for healing of surgical site and assessment for possible reoccurrence could not be done.
Figure 4: Postoperative view of the surgical site showing complete excision of the lesion

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Excised tissue [Figure 5] was sent to the department of oral and maxillofacial pathology for histopathological examination. The specimen was fixed and stained with hematoxylin and eosin stain. Histological view [Figure 6] showed central fibrovascular core with hyperplastic squamous epithelium. Finger-like papillary projections were seen in the connective tissue. There was a presence of basilar hyperplasia with the presence of koilocyte-like cells. A final diagnosis of squamous cell papilloma was made on the basis of clinical and histopathological presentation.
Figure 5: Excised lesion

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Figure 6: Papillary projection and hyperplasic epithelium (a) showing keratinized epithelium and connective tissue core (×4) and (b) showing basal cell hyperplasia and papillary projection (×20)

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   Discussion Top

Oral squamous papilloma is usually appears as a small lesion progressing within a duration that varies from a few weeks to 10 years. In spite of it being a common benign neoplasm of the oral cavity, its occurrence in the gingiva is relatively rare. The viral life cycle starts upon entering of virus to basal layer through a microabrasion. After cell division, viral proteins E1, E2, E6, and E7 are expressed at low levels and migration of infected cell to the suprabasal layer is found.[2],[3] Isolated lesions are associated with spinous layer proliferation in a papillary pattern.[4]

Although, generally, it occurs in patients aged between 30 and 50 years, Brooks et al.[5] reported a case of gingival squamous cell papilloma arising from labial as well as lingual interdental gingiva in a 4-year-old boy which recurred twice after excision. We observed an unusual “garlanding a tooth” type of appearance in our case which had a wide and very clearly defined papillary projection unlike the case reported by Ye et al. which had minimal extension on interdental papilla.[6] A gingival lesion was also reported in a 20-year-old male by Ozcan et al.[7] where a diode laser was used for excision. However, the lesion showed a recurrence after 6 months. To prevent further recurrence, in addition to surgery, the patient received Cervarix vaccine.

Histology is an important method for diagnosing the lesion. However, if histology is unable to identify, molecular biology techniques should be explored. Polymerized chain reaction and immunoabsorbant assays are the other two alternative methods to investigate the viral etiology.[8] Along with the viral etiology, smoking is another accelerating factor to initiate squamous cell papilloma. No laboratory test was carried out for viral etiology. We would like to submit that such investigations are not only difficult but also expensive. Again, it is not necessary that the viral etiology may be established in each case. There is, however, enough historical evidence that squamous cell papilloma is usually associated with HPV.

Carneiro et al.[8] demonstrated some strict histopathologic criteria: (i) finger-like projection of squamous epithelium, (ii) hyperkeratosis and normal maturation process, and (iii) perinuclear cytoplasmic vacuolation. On examination, it revealed a cauliflower-like nontender, asymptomatic growth. This lesion is difficult to differentiate from verruciform xanthoma, condyloma acuminatum, or Darier's disease. Surgical excision and laser ablation are the treatment of choice.[9] Lactic acid and liquid nitrogen can be used for smaller lesions.

Malignant potential of this lesion albeit low exists. However, the likelihood of it progressing into malignancy depends on the type of virus, its combined action with various physical, chemical, biological agents, the genetic constitution, and the host immune defense. In an exploration of several studies, it was reported that the most commonly detected HPV type in oral squamous cell carcinoma and oral potentially malignant disorders was HPV-16 and HPV-18, while HPV-6 and HPV-11 were found in only a few studies. In addition, expression of markers of progression of malignancy BCL2 gene and p53 gene was not found to be associated with HPV-positive oral squamous cell carcinoma and the mutations in p53 were rarely seen in HPV-positive tumors compared with HPV-negative tumors.[2] Further, a quadrivalent vaccine (Gardasil) has recently been proposed to prevent viral infections of HPV-6 and HPV-11,[10] by creating a robust humoral response much more effective than the levels of antibodies acquired after a general viral infection.

   Conclusion Top

Oral squamous cell papilloma is closely associated with HPV. A dental surgeon is under an obligation to examine the oral cavity of patients looking for lesions that may be caused by HPV since some of them may have neoplastic changes. Detection at an early stage may prevent the complications of the disease, and the management can be done by minimally invasive way.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Andrade SA, Pratavieira S, Paes JF, Ribeiro MM, Bagnato VS, Varotti FP. Oral squamous papilloma: A view under clinical, fluorescence and histopathological aspects. Einstein (Sao Paulo) 2019;17:eRC4624.  Back to cited text no. 1
Gupta S, Gupta S. Role of human papillomavirus in oral squamous cell carcinoma and oral potentially malignant disorders: A review of the literature. Indian J Dent 2015;6:91-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Syrjänen S. Oral manifestations of human papillomavirus infections. Eur J Oral Sci 2018;126 Suppl 1:49-66.  Back to cited text no. 3
Singh A, Malik U, Malhotra S, Kumar A. Squamous papilloma: A report of two cases with review of literature. J Indian Acad Oral Med Radiol 2016;28:102.  Back to cited text no. 4
  [Full text]  
Brooks JK, Poshni K, Khoury ZH, Basile JR. Recurrent gingival squamous papilloma: A rare finding in a child. J Dent Child (Chic) 2017;84:145-8.  Back to cited text no. 5
Ye CC, Huang HY, Gao Y, Huang P, Wu YF. Squamous cell papilloma in interdental papilla: A case report. Hua Xi Kou Qiang Yi Xue Za Zhi 2009;27:235-6.  Back to cited text no. 6
Ozcan E, Canakei CF, Filinte D. Importance of the vaccination in recurrent squamous papilloma on the gingiva. Pak Oral Dent J 2011;31:160-2.  Back to cited text no. 7
Carneiro TE, Marinho SA, Verli FD, Mesquita AT, Lima NL, Miranda JL. Oral squamous papilloma: Clinical, histologic and immunohistochemical analyses. J Oral Sci 2009;51:367-72.  Back to cited text no. 8
Rakhewar P, Patil H, Thorat M. Diode laser treatment of an oral squamous papilloma of soft palate. J Dent Lasers 2015;9:114-7.  Back to cited text no. 9
  [Full text]  
Lowy DR. HPV vaccination to prevent cervical cancer and other HPV-associated disease: From basic science to effective interventions. J Clin Invest 2016;126:5-11.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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