Focal Epithelial Hyperplasia (Heck Disease): HPV Lesions in Children

Focal epithelial hyperplasia (FEH), also known as Heck disease or multifocal epithelial hyperplasia, is a rare benign condition of the oral mucosa strongly associated with human papillomavirus (HPV) types 13 and 32.

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It predominantly affects children and adolescents, particularly in certain indigenous and genetically predisposed populations. Clinically, it presents as multiple soft papules or nodules on the lips, buccal mucosa, and tongue.

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The lesions are usually asymptomatic and may regress spontaneously. Accurate recognition is essential to distinguish FEH from other HPV-related lesions and avoid unnecessary treatment. Management includes observation, biopsy when diagnosis is uncertain, and lesion removal when esthetic or functional problems occur.

✅ Introduction
Focal epithelial hyperplasia (FEH) is an uncommon oral mucosal disorder first described in 1965 by Archard, Heck, and Stanley. The condition is characterized by multiple, smooth, flattened or dome-shaped papules of normal mucosal color. FEH is caused by infection with low-risk HPV types 13 and 32, which are not associated with malignant transformation. Although benign, the disease is of considerable importance in pediatric dentistry because it may mimic other viral or neoplastic lesions and can generate anxiety among parents and caregivers.

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✅ Clinical Characteristics of Heck Disease

Typical Oral Findings
▪️ Multiple and well-circumscribed
▪️ Soft and sessile
▪️ Pink to mucosal-colored
▪️ Smooth or slightly papillary
▪️ Asymptomatic

Common Sites
▪️ Lower lip mucosa
▪️ Buccal mucosa
▪️ Lateral borders of the tongue
▪️ Labial mucosa
▪️ Gingiva (less common)

Distinctive Feature
A classic sign is that many lesions become less visible or flatten when the mucosa is stretched.

Age Group
FEH occurs most frequently in:
▪️ Children
▪️ Adolescents
▪️ Young adults

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✅ Etiology

The principal etiologic agents are:
▪️ HPV type 13
▪️ HPV type 32

Predisposing factors include:
▪️ Familial clustering
▪️ Genetic susceptibility
▪️ Crowded living conditions
▪️ Poor oral hygiene
▪️ Malnutrition
▪️ Immunosuppression

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✅ Is Focal Epithelial Hyperplasia Contagious?
Yes. FEH is associated with transmissible HPV infection, although the virus has relatively low pathogenicity.

Possible Routes of Transmission
▪️ Salivary contact
▪️ Sharing utensils or toothbrushes
▪️ Close household contact
▪️ Autoinoculation
▪️ Perinatal transmission
Importantly, Heck disease in children is not considered a sexually transmitted infection.

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✅ Differential Diagnosis
The differential diagnosis includes:

▪️ Squamous papilloma
▪️ Verruca vulgaris
▪️ Condyloma acuminatum
▪️ Multifocal papillomatosis
▪️ Cowden syndrome-associated papillomas

Definitive diagnosis is based on:
▪️ Clinical examination
▪️ Histopathology
▪️ HPV detection by PCR (optional)

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✅ Histopathological Features
Characteristic microscopic findings include:

▪️ Acanthosis
▪️ Parakeratosis
▪️ Broad and elongated rete ridges
▪️ Mitosoid cells (highly suggestive of FEH)
▪️ Koilocyte-like changes

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✅ Treatment

Observation
Most lesions are asymptomatic and may regress spontaneously over months to years.

When Treatment Is Indicated
Treatment may be considered when lesions:
▪️ Interfere with speech or mastication
▪️ Are repeatedly traumatized
▪️ Cause esthetic concerns
▪️ Persist without regression
▪️ Create diagnostic uncertainty

Therapeutic Options
▪️ Surgical excision
▪️ Laser ablation
▪️ Cryotherapy
▪️ Electrocautery
▪️ Topical imiquimod (selected cases)

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✅ Prevention
Although no specific preventive strategy guarantees complete protection, risk can be reduced through:

▪️ Good oral hygiene
▪️ Avoiding sharing toothbrushes and utensils
▪️ Nutritional optimization
▪️ Routine dental examinations

Role of HPV Vaccination
Current vaccines, including Gardasil 9, do not specifically target HPV 13 or 32. However, some authors have hypothesized a possible indirect benefit, although conclusive evidence is lacking.

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✅ Dental Management and Professional Action
The dentist should:

1. Recognize the characteristic appearance of FEH.
2. Reassure parents about its benign nature.
3. Document lesion distribution and size.
4. Eliminate local irritants.
5. Request biopsy when diagnosis is uncertain.
6. Monitor periodically.
7. Refer to oral pathology or pediatric specialists when necessary.

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💬 Discussion
Focal epithelial hyperplasia is an uncommon but distinctive oral manifestation of low-risk HPV infection in children. The condition is particularly relevant in pediatric dentistry because its multifocal presentation may resemble condyloma acuminatum or other proliferative lesions, potentially leading to misinterpretation and unnecessary concern. The absence of malignant potential and the high frequency of spontaneous regression support conservative management in most cases. Biopsy is reserved for atypical lesions, persistent growth, or uncertain diagnosis. Awareness of this condition enables appropriate counseling and evidence-based treatment.

✍️ Conclusion
Focal epithelial hyperplasia (Heck disease) is a benign HPV-related oral lesion caused primarily by HPV 13 and 32. It occurs predominantly in children and usually presents as multiple asymptomatic papules on the oral mucosa. Because the lesions often regress spontaneously and have no known malignant potential, conservative monitoring is the preferred approach. Accurate diagnosis and parental reassurance are essential components of pediatric dental care.

📚 References

✔ Archard, H. O., Heck, J. W., & Stanley, H. R. (1965). Focal epithelial hyperplasia: An unusual oral mucosal lesion found in Indian children. Oral Surgery, Oral Medicine, and Oral Pathology, 20(2), 201–212. https://doi.org/10.1016/0030-4220(65)90192-1
✔ Bendtsen, S. K., Jakobsen, K. K., Carlander, A.-L. F., Grønhøj, C., & von Buchwald, C. (2021). Focal epithelial hyperplasia. Viruses, 13(8), 1529. https://doi.org/10.3390/v13081529
✔ Conde-Ferráez, L. C., & González-Losa, M. del R. (2024). Multifocal epithelial hyperplasia: An understudied infectious disease affecting ethnic groups. Frontiers in Cellular and Infection Microbiology, 14, 1420298. https://doi.org/10.3389/fcimb.2024.1420298
✔ Syrjänen, S. (2018). Oral manifestations of human papillomavirus infections. European Journal of Oral Sciences, 126(Suppl. 1), 49–66. https://doi.org/10.1111/eos.12538

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