Oral Florid Papillomatosis Clinical Presentation

Updated: Apr 16, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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The patient may note a bulky tumor. Some patients experience localized pain and difficulty in mastication. Malignant conversion of florid oral and labial papillomatosis during topical immunotherapy with imiquimod was described in one patient. [42]


Physical Examination

The Ackerman tumor is evident as a confluence of whitish nonulcerated papillomas on the oral mucosa, often on a background of chronic irritation or leukoplakia. The surface may be pebbly or mamillated. [2] Leukoplakia may be the earliest sign. [29] Proliferative verrucous leukoplakia tends to recur after treatment and has an elevated rate of malignant transformation. [43] The tumor may begin on the vermillion border of the lip or extend onto it. Of the 31 patients that Ackerman described, 18 had verrucous carcinoma on the buccal mucosa; 8, on the lower gingiva; 2, on the hard palate; and 1 each, on the upper gingiva, the tongue, and the tonsil.

The most common sites are the inner aspects of the cheek along the bite line and the gingiva. Verrucous carcinoma slowly extends into locally contiguous sites. It may expand into the mandible or to the cheek from the inner buccal surface.  It may be evident as a verrucous mass on the tongue. [44]

Concurrent infection is common, and the resultant enlarged and tender lymph nodes may be mistaken for malignant involvement of the regional lymph nodes. Concurrent infection can create the impression that the tumor is indurated rather than soft. Despite advancement near the lymph nodes, verrucous carcinoma invariably grows around them rather than metastasizing to them.



Verrucous carcinoma is a locally aggressive and destructive tumor that advances into adjacent bone and other structures. Regional lymph node metastases occasionally occur, but distant metastases are rare. Rapid anaplastic transformation with widespread metastases has been described in a few patients with oral verrucous carcinoma. This complication mainly occurs after radiation therapy.