Lesions are exophytic and comprise folds of hyperplastic stratified epithelium that are usually thickly para- or orthoker-atinized but may be non keratinised. Squamous papillomas associated with HPV (oral verruca vulgaris) comprise a cluster of finger-like projections from a narrow base, each with a sharp kera-tinised tip, supported on ramifying cores of connective tissue containing dilated capillaries. Stratification of the epithelium is well ordered. Mitoses may be frequent and there may be mild anisonucleosis consistent with hyperplasia, but no atyp-ia. The fronds are thickly keratinised, often with a prominent keratohyaline layer of large coarse granules. Small foci of HPV-infected cells (koilocytes) can usually be found in the upper prickle cell layer. These keratinocytes have crumpled, darkly stained nuclei with perinu-clear haloes but appear very similar to vacuolated keratinocytes that are common in the normal oral mucosa. Koilocytes may be more frequent in early lesions. Less frequently, viral inclusions are found. Rete processes at the base often turn inwards and are symmetrical. Small foci of lymphocytic inflammation may lie in the fronds or at the base but inflammation is usually sparse unless the lesion is subject to trauma or other irritation {4,1929}. HPV may be identified by immunocytochemistry or in-situ hybridisation but this is not necessary for diagnosis {2076}.

Papillomas without detectable active HPV replication show more variation.

They may appear identical to verruca vulgaris but without koilocytes or prominent keratohyaline granules, or form rounded broad-based dome shaped lesions similar to condyloma. The hyper-plastic epithelium may form papillary exophytic fronds or arborising rete processes. Some are flat zones of acan-thotic hyperplastic epithelium with increased numbers of dermal papillae similar to plane warts of the skin.

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