Scientific Article

Condyloma Acuminatum and Human Papilloma

Virus Infection in the Oral Mucosa of Children
Liu Lai Kui, PhD He Zhi Xiu, MD Li Yi Ning, DDS
Dr. Kui is assistant professor, Dr. Xiu is professor, and Dr. Ning is assistant professor, Department of Oral Pathology,
West China College of Stomatology, Sichuan University, Chengdu, Sichuan, The People’s Republic of China.
Correspond with Dr. Kui at [email protected]

Abstract
Purpose: The purpose of this study was to investigate the clinicopathological features of
oral condylomas in children and condylomatous lesions of their mothers. Moreover, the
authors sought to determine the mode of transmission of this disease and to find the
genotype of human papilloma virus (HPV) in the children’s oral condyloma.
Methods: Nine instances of oral condyloma acuminatum in children and lesions in their
mothers were reviewed. Their HPV genotypes were evaluated by in situ hybridization
(ISH).
Results: This study revealed that the lesions appeared during 3 years of age and the most
common location was the hard and soft palate. Seven of the 9 mothers had experienced
vulva and/or oral cavity condylomata during pregnancy. Social evaluation confirmed
sexual abuse in 1 girl, and probable sexual abuse in another girl. The results of ISH dem-
onstrated HPV 16/18 DNA being positive in 5 of the 9 cases, and HPV 6 and HPV 11,
HPV 6 and HPV 16/18, HPV 6, and HPV 11 DNA being positive, respectively, in 1
case. HPV DNA types in mother-child pairs were not concordant.
Conclusions: Oral condyloma acuminatum in children is probably induced by HPV 16/
18. The mode of transmission by sexual abuse is the most likely route. Prenatal trans-
mission of HPV to children is rare. This study provides further confirmation of possible
different genotype and transmission in oral CA of children and adults. (Pediatr Dent.
2003;25:149-153)
KEYWORDS: CHILDREN, ORAL MUCOSA, CONDYLOMA ACUMINATUM, HUMAN PAPILLOMA VIRUS
Received May 13, 2002 Revision Accepted November 14, 2002

C
ondyloma acuminatum (CA) is a benign papillary and appears to be related to an increase of condylomata in
lesion that is commonly found on anogenital tract adults.13 However, there is little data concerning oral mu-
skin and mucosa.1,2 These benign epithelial lesions cosa condylomata in children. In this paper, the
are associated with human papilloma virus (HPV), the ma- clinicopathological features of 9 instances of oral condylo-
jority being types 6 and 11.3 Oral condyloma acuminatum mas in children have been studied and their HPV genotypes
has been reported to be resulted from genital-oral sexual have been evaluated by in situ hybridization.
transmission or hand-to-mouth autoinoculation in
adults.4,5 Some authors believe that the presence of condy- Methods
lomata in children may be due to sexual abuse.6-8 However,
an earlier study of children with anogenital CA and their Case selection
parents provides further confirmation of possible nonsexual Nine cases of children’s oral condyloma acuminatum were
transmission through prenatal infection, digital inoculation reviewed in the department of oral pathology, West China
or autoinoculation, fomites, and casual social contact.9,10 College of Stomatology, Sichuan University, Sichuan,
Oral condyloma has also been reported in association with China. Differentiation from the more common squamous
HIV status in children.11 As currently known, the fre- papilloma was made employing criteria specified for
quency of childhood condylomata is steadily increasing9,12 anogenital condylomata.14 All cases in this study exhibited

Pediatric Dentistry – 25:2, 2003 Condyloma acuminatum in children Kui et al. 149
 DNA in situ hybridization
In situ hybridization was performed with HPV 6, 11, and
16/18 probes from a viral-type in situ hybridization kit
according to the manufacturer’s directions. Each specimen
was cut 4 to 6µm thick and placed on a glass slide treated
with 3-aminopropyltriethoxysilane, then allowed to adhere
at 60˚C overnight. Sections were dewaxed in xylene and
dehydrated in pure ethanol. The slides were then air dried
and incubated with digestion reagent (37˚C for 15 min-
utes). Digoxin probes for HPV 6, 11, and 16/18 were
applied to the sections and denatured (100˚C for 5 min-
utes) in a water bath. The sections were then removed from
the water bath and placed in a 37˚C incubator overnight
to allow for DNA hybridization between tissue and probes.
Figure 1. Children’s oral condyloma acuminatum—cytopathic changes Posthybridization washes were incubated with rabbit anti-
in the superficial cells of condyloma acuminatum showing numerous Digoxin and biotinylated goat antirabbit at 37˚C for 30
koilocytes and slight hyperparakeratosis (H and E ×200).
minutes.15-17

papillomatosis with a tendency for a sessile rather than Controls

predunculated architecture. Clinically, the surface of Two genital condylomata were used as positive controls.
condylomas appears as a cauliflower-like lesion that is the Negative controls consisted of normal oral tissues.
result of multiple, small white or pink nodules that coa-
lesce to produce a soft, nodular mass. Histologically, Results
invaginations of these parakeratinized cells are often Clinical data of oral condyloma in children and lesions in
present, along with marked acathosis. Koilocytes (vacu- their mothers is presented in Table 1. The lesions appeared
olated cells) are common in the upper spinous and corneal in children between 1 year, 4 months to 6 years of age. Six
layers (Figure 1). All children received an environmental of the 9 children were girls, and 1 of them recurred 10
risk assessment for sexual abuse. month after treatment. The most common location was the
Nine volunteer mothers whose children presented with palate, with only 2 cases in the commissure. The recurred
oral condyloma acuminatum accepted histological exami- lesions located in the palate, and also in the lower lip. Seven
nation of the lesions from the oral cavity or anogenital of the 9 mothers suffered from vulva or/and oral cavity
regions. The authors were unable to obtain adequate data condylomata during pregnancy.
on the conditions of the children’s fathers. All children had Social evaluation confirmed sexual abuse in 1 girl, and
surgical excision of the lesions, but 1 case recurred 10 probable sexual abuse in another girl.
months later. The results of HPV DNA in situ hybridization are pre-
sented in Table 2. The specific hybridization signal was
localized in the nuclei of su-
Table 1. Clinical Data of Oral Condyloma in Children and Lesions in Their Mothers perficial spinous layer cells
Lesions in their mothers (Figure 2). The majority of
positive cells exhibited
Case Age at Site of Sexual Site of During
no. onset Sex lesion abuse lesion Diagnosis pregnancy koilocytotic alterations. In
1 2 y, 1 mo F Palate No Vulva CA* Yes
most instances, the distribu-
tion of positive signal was
2 6y F Commissure Suspicion No lesion No No
focal. The results of ISH
3 2 y, 6 mo F Palate No Vulva CA Yes demonstrated HPV16/18 be-
4 4y F Palate Yes Vulva CA No ing positive in 5 of the 9
5 Vulva cases: one case positive for
1 y, 6 mo M Palate No and cavity CA Yes both HPV 6 and 11; another
6 4 y, 6 mo F Commissure No Vulva CA Yes case positive for both HPV 6
7 3y M Palate No Vulva CA Yes and 16/18; one case positive
8 4y F Palate No Vulva CA Yes for HPV 6 and one case posi-
tive for HPV 11.
9 1 y, 4 mo M Palate No No lesion No No
All positive control
9 Palate and samples were color reactive.
(recurred) 2 y, 2 mo M lower lip No No lesion No No
The negative control samples
were nonreactive (Figure 3).
*Condyloma acuminatum.

150 Kui et al. Condyloma acuminatum in children Pediatric Dentistry – 25:2, 2003
 Discussion casual transmission Table 2. HPV Distribution in
Condyloma acuminatum has been reported to occur in the of lesions to the oral Children and their Mothers
oral cavity, however, most published instances are adults.18-20 cavity in children as Demonstrated by
In Situ Hybridization
In this study, 9 instances of CA have been found in the remains, therefore,
oral cavity of children. The lesion appeared at about 3 years conjectural. Case HPV In situ
of age. The common location of children’s oral CA, which In this investiga- no. genotypes hybridization
is located in the palate, is different from those of adults that tion, the authors Children Mother
are often located in the lower lip and tongue.17,21 demonstrate that 1 16/18 6
Data indicate that the primary means of transmission HPV 16/18 is the 2 16/18 Negative
of adult’s condylomata is by sexual contact with a person most common HPV 3 6, 11 6, 11
infected with HPV.22-24 Most publications concerning pe- type (6 out of 9
4 6, 16/18 6
diatric anogenital warts authored by clinicians who work cases). In contrast,
with child protection services have concluded that the some studies report a 5 6 16/18
majority of children whose lesions were recognized after high percentage of 6 11 11
infancy had been sexually abused.25 Oral lesions due to HPV 6 and HPV 11 7 16/18 6
HPV have been reported in children, several of whom had oral mucosa infec- 8 16/18 6
been sexually abused.26,27 In this study, sexual abuse was tions in adults with 9 16/18 Negative
confirmed in 1 girl, and there was a suspicion of sexual CA. 17 The relative
9 (recurred) 16/18 Negative
abuse in another girl. But children are difficult to assess for lower incidence of
Positive
sexual abuse because of preverbal or limited verbal abili- HPV 6 and HPV 11 controls Positive
ties. A child who has not been evaluated for abuse cannot may represent a
Negative
be assumed to be nonabused28,29 so the mode of transmis- lower diffusion of controls Negative
sion by sexual abuse must be considered. these viruses within
Perinatal transmission of HPV to infants and toddlers the oral cavity of
is possible in theory. Most experts agree that HPV lesions children with CA, or
seen on any part of the body of a child younger than 1 year an underestimation due to the sample size. Mixed infections
of age can be the result of vertical transmission from an in- were revealed in 2 of 9 instances, corresponding to findings
fected mother.25 In this study, the lesion had appeared at reported for anogenital region lesions.30 HPV 6 DNA was
about 3 years of age, so vertical transmission is considered presented in both of the mixed infections. It is still unclear
to be unlikely. On the other hand, although mothers of 7 whether oral mucosa in children is vulnerable to infection
of the 9 children suffered from vulva or oral condyloma by HPV 16/18, and whether the presence of HPV 6 predis-
acuminatum during pregnancy, the unexpected finding poses to infection by other HPV types. Further analysis is,
showed some discordance between the HPV type in CA therefore, necessary to confirm this hypothesis.
of children and mothers. This finding is supported by most HPV 16/18 is still positive in 1 recurred case. This is
experts, which suggests that vertical transmission of HPV supported by previous studies that childhood CA caused
to children is rare. In addition, the authors were unable to by low-risk HPV 6 and HPV 11 may have been spontane-
obtain adequate data to demonstrate if the children’s HPV ously resolved, while chronic HPV infection may have been
types were concordant with their contact. Atraumatic and correlated with the high-risk types HPV 16/18.31 These
types are also highly associated with mucosal carcinoma in

Figure 2. HPV DNA in koilocytes of children’s oral condylomata (in Figure 3. This photograph shows nonreactive HPV DNA negative
situ hybridization ×200). control samples (in situ hybridization ×100).

Pediatric Dentistry – 25:2, 2003 Condyloma acuminatum in children Kui et al. 151
adults.32,33 Hence, a prolonged follow-up is necessary for 12. Lacey CHJN. Genital warts in children.
HPV 16/18 infection in children. Papillomavirus Report. 1991;2:31-32.
13. Koutsky LA, Galloway DN, Holmes KK. Epidemi-
Conclusions ology of genital human papilloma virus infection.
The majority of incidences of oral condyloma acuminatum Epidemiol Rev. 1988;10:122-162.
in children are caused by HPV 16/18. Sexual abuse is the 14. Lever WF, Schaumburg-Lever G. Histopathology of the
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ABSTRACT OF THE SCIENTIFIC LITERATURE

EFFECTS OF WATER STORAGE ON EXPANSION AND BOND STRENGTH OF 4 RESIN
COMPOSITES
The authors of this study wanted to test the hypothesis that resinous materials with relatively large water
absorption will show reduced gap sizes around fillings in cavities as well as reduced mechanical strength.
Therefore, the aim of their study was to test and compare the hygroscopic expansion in dentin cavities of a
compomer (Dyract AP), an ormocer (Definite), an ion-releasing resin composite (Ariston pHc), and a tra-
ditional resin composite (Spectrum TPH), and to measure changes in mechanical properties of the materials
due to extended water storage. Cavity preparations were made on flattened dentinal surfaces of extracted
human teeth of approximately 3.1 mm in diameter with a depth of 1.5 mm. The preparations were slightly
overfilled and cured using no dentin pretreatment and stored at 37ºC in water. Microscopic examination of
the maximal gap at the cavity margin between dentin and polymerized material was measured after 1 hour,
1 day, 7 days, 30 days, 90 days, and 180 days in water storage with the excess material removed immediately
before inspection. Those that were examined after 1 hour were put back into water storage and examined
again after 1, 7, 30, 90 and 180 days. Flexural strength was also measured at all time points, and the results
were compared. The authors found that, in all cases, extended water storage caused a significant reduction
in the sizes of the marginal gaps and, with 2 of the materials (DYR and ARI), a very small or absence of
marginal gaps was apparent after 180 days in water storage. Flexural strengths for each material did not
differ significantly from 1 to 180 days. The authors concluded that the gap sizes were reduced but the me-
chanical properties were either unaltered or increased in the range of 1 to 180 days of water immersion.
Comments: Although this in vitro test using a cylindrical cavity preparation does not equate to their use
in vivo, it does allow for direct comparisons of various composite resin materials. DARB
Address correspondence to Erik Christian Munksgaard, Department of Dental Materials, School of Dentistry,
University of Copenhagen, 20 Norre Alle, DK-2200 Copenhagen N, Denmark. [email protected]
Munksgaard EC. Changes in expansion and mechanical strength during water storage of a traditional
and three modified resin composites. Acta Odontol Scand. 2002;60:203-297.
20 references

Pediatric Dentistry – 25:2, 2003 Condyloma acuminatum in children Kui et al. 153