Oral Warts

Background

Oral warts are caused by human papillomavirus (HPV) and may appear anywhere within the oral cavity or on the lips. They occur more frequently and more extensively in people with HIV infection than in those with normal immune function, especially in patients with advancing immune suppression (CD4 counts of <200-300 cells/µL). Oral warts may be refractory to therapy. The frequency of oral warts may increase, at least temporarily, in patients treated with antiretroviral therapy.

It should be noted that HPV infection is strongly associated with oropharyngeal cancer among subjects with or without the established risk factors of tobacco and alcohol use, although oral warts normally are not caused by the HPV types that are associated with oncogenic changes. One analysis of stored samples suggests that the percentage of all oropharyngeal cancers that are HPV-positive has increased from about 20% to 60% since about 1980. Researchers also have reported that HPV-related oral cancers were among the most responsive to chemotherapy and radiation.

S: Subjective

The patient notices raised lesions in the mouth or on the lips. Warts are not painful unless they have been traumatized.

O: Objective

Examine the oral cavity carefully for abnormalities. Wart lesions may vary in appearance from smooth, small, and slightly raised lesions to cauliflower-like or spiked masses with prominent folds or projections. They may be single or multiple.

Review recent CD4 counts. In patients with oral warts, the CD4 count usually is <300 cells/µL.

A: Assessment

A partial differential diagnosis includes: squamous cell carcinoma, lichen planus, and traumatic hyperkeratinized areas resulting from cheek biting or tongue thrusting.

P: Plan

Diagnostic Evaluation

• The diagnosis of oral warts usually is based on the appearance of the lesions. If lesions are unusual in appearance, are ulcerated, or have grown rapidly, perform biopsy to rule out cancer. If there is suspicion of other causes, perform other diagnostic evaluations as indicated.
• HPV may be demonstrated with electron micropsy or in situ hybridization; this testing is not routinely required.
• Observation of these lesions is important because of the potential, however minimal, for development of squamous cell carcinoma.

Treatment

• Treatment is difficult, as these lesions tend to recur. Treatment options include cryosurgery and surgical or laser excision. Care must be taken when using laser excision, as HPV can survive in an aerosol. Extraoral lesions (lip or corner of mouth) may be treated with topical agents such as podofilox topical solution (Condylox) or fluorouracil 5% topical (Efudex). Imiquimod 5% cream (Aldara) may help to prevent recurrence once the lesions have resolved.
• Refer to an oral health specialist or dentist for treatment.

Patient Education

• Instruct patients to comply with regular dental and medical care regimens.
• Instruct patients to use medications exactly as prescribed.

References

• Greenspan D, Canchola AJ, MacPhail LA, et al. Effect of highly active antiretroviral therapy on frequency of oral warts. Lancet. 2001 May 5;357(9266):1411-2.
• King MD, Reznik DA, O'Daniels CM, et al. Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection. Clin Infect Dis. 2002 Mar 1;34(5):641-8.