2015, Volume 31, Number 1, Page(s) 060-063
Oral Focal Epithelial Hyperplasia: Report of Three Cases
Parichehr GHALAYANI1, Payam TAVAKOLI2, Mehdi EFTEKHARI3, Mohammad Akhondzadeh HAGHIGHI1
1Department of Oral Medicine and Torabinejad Dental Research Center, Isfahan University of Medical Sciences, School of Dentistry, ISFAHAN, IRAN
2Department of Oral & Maxillofacial Pathology, Kermanshah University of Medical Sciences, School of Dentistry, KERMANSHAH, IRAN
3Department of General Pathology, Ahwaz University of Medical Sciences, School of Medicine, AHWAZ, IRAN
Keywords: Focal epithelial hyperplasia, Heck disease, Buccal mucosa
Focal epithelial hyperplasia or Heck's disease is an infrequent
asymptomatic condition caused by human papillomavirus types 13
or 32 affecting the mucous membrane of the mouth and is commonly
seen in young individuals. Firstly, it was described in Indians and
Eskimos, but it exists in various populations. We present three cases
of Heck's disease in an Afghan immigrant family group living in Iran
that seem to have familial predominance. The disease was identified
as oral focal epithelial hyperplasia on the basis of histopathologic
and clinical findings. The lesions were reduced significantly after 4
months of good oral hygiene. Dentists should be familiar with the
clinical manifestations of these types of lesions that affect the oral
cavity. In fact, histopathologic assessment and clinical observation
are necessary to establish the diagnosis.
One of the most contagious oral lesions is focal epithelial
hyperplasia or Heck's disease, induced by human
papillomavirus (HPV). The earliest description of the
condition was in 1965 by Archard et al in Native Americans
. The disease is more common among younger
age groups and occasionally there is some tendency to
occur in families. This familial tendency may be related to
either genetic susceptibility or HPV transmission between
The most common sites of involvement include the labial,
buccal, and lingual mucosa, but gingival and palatal lesions
also have been reported. This disease normally manifests
as multiple soft, flattened or rounded papules, which are
usually clustered and the color of normal mucosa, although
they may be scattered, pale, or rarely white. Notably, the
lesions have a tendency to disappear on their own1,2.
There is an etiological link between papillomavirus and this
lesion. Moreover, living conditions such as malnutrition,
poor hygiene and also genetic factors have been related to
This paper reports 3 cases of focal epithelial hyperplasia
that have familial predominance in an Afghan family
group. Besides, the diagnosis is based on histopathological
Three patients from an Afghan community were referred
to the department of oral pathology, school of dentistry,
Isfahan University of Medical Sciences. Two of the cases
were siblings and one of whom was their uncle.
Case 1 was a 30 years old man suffering from painless small
elevations on oral mucosa in the last 6 months. He had no
history of previous systemic disease, and he had not taken
any medications. His oral examination revealed normalcolored
to white papules, mainly located on the buccal mucosa, mucosa of the lower lip and tongue. The lesions
were not ulcerated nor inflamed (Figure 1A).
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|Figure 1A, B: Patient with multiple lesions in labial and buccal
Case 2 was the nephew of case 1. She was a 12-year-old girl
presented with about 5 months history of asymptomatic
growths on her mouth. The patient did not report any
systemic disease. Her oral examination revealed several
papules measuring 0.2 to 1.0 cm extended over the buccal
and labial mucosa. Moreover, the lesions on the right
cheek occasionally had interference with mastication that
resembled a string of beads (Figure 1B).
Case 3 was the brother of case 2. He was a 5-year-old
boy without any systemic condition who complained of
multiple asymptomatic lesions in his mouth for about 5
months. Intraoral examination showed multiple elevated
pinkish papules on the buccal, upper and lower lip mucosa.
All three patients described here were presented with poor
The clinical diagnosis of focal epithelial hyperplasia
was straightforward; however, in order to confirm the
diagnosis a biopsy was performed on the largest lesions of
labial and buccal mucosa after applying local anesthesia
and the specimens were submitted for histopathologic
evaluation. The histopathological assessment showed a
squamous epithelium displaying regional parakeratosis,
acanthosis (Figure 2A), basal cell hyperplasia, vacuolization
of numerous epithelial cells (koilocytosis) (Figure 2B),
Occasional binucleation and nuclear irregularity. There
was no epithelial dysplasia. Also, collapsed nucleus that
resembles a mitotic figure (mitosoid cell) was obvious
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|Figure 2: Histopathology of Heck disease. A) Acanthosis of the
epithelium with broad and elongated rete ridges (H&E; ×100).
B) Isolated perinuclear cellular vacuolization (H&E; ×400).
C) Mitosoid cell (H&E; ×1000).
We advised the patients to have better oral and general
hygiene. The lesions disappeared remarkably after 4 months
illustrated in figure 3A and 3B.
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|Figure 3A,B: Remission of the lesions after 4 months of promoting
good oral hygiene.
Focal epithelial hyperplasia is an HPV induced epithelial
proliferation. This disease appears to be uncommon.
According to literature, a few cases of Heck's disease have
been reported in Iran4,5
. This might be due to lack of the
reports. We show three cases of focal epithelial hyperplasia
in Afghan patients. Children are affected more frequently
with a female-to-male predilection of approximately 4–5:16,7
. The multiple papillary lesions like Heck's disease are
especially common among HIV positive individuals8
The human papillomavirus is associated with proliferations
of squamous mucosa in this process. Type 13 and 32 has
been detected with polymerase chain reaction9,10. It
should be mentioned that HPV 6, 11 and 18 have been found as well11. The oral cavity can be the site of a variety
of HPV-related lesions, some of which are microscopically
and behaviorally benign. These include focal epithelial
hyperplasia (Heck's disease), verruca vulgaris, condyloma
acuminatum and squamous papilloma12. Human-tohuman
transmission has been assumed to be the most
important mode of contact. However, the virus could be
transmitted from mother to child12. This helps to explain
why Heck disease occurs in child group and its familial
tendency. Notably, poor nutrition, hygiene and overall
health may be related to disease5. These conditions
comply with our cases.
Histological examination illustrated acanthosis of the oral
epithelium. The rete ridges were widened, often confluent,
and sometimes club shaped. Some superficial keratinocytes showed a koilocytic change similar to that seen in other
HPV infections. Others occasionally demonstrate an altered
nucleus that resembles a mitotic figure (mitosoid cell)13.
Spontaneous regression of multifocal epithelial hyperplasia
has been reported after months or years by enhancing oral
and general hygiene (as we observed in all 3 patients),
nevertheless, application of local cryotherapy has been used
as well14. Also, application of vitamin A and sulfamides
has been recommended by Archard and co-workers1.
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