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FACT SHEET: Human Papillomavirus and Warts (also known as “HPV infection” and “warts virus”; various wart forms also known as common or “verruca vulgaris”, flat, filiform, periungal, mosaic, hyperkeratotic, and plantar; STI-related/genital warts also known as “condylomata acuminata” or “papilloma venereum”; HPV infection also includes focal epithelial hyperplasia [FEH, or Heck’s disease]; caused by 100+ types of human papillomavirus [HPV], some of which cause oral/oropharyngeal cancer; sexually transmitted form also known generically as a “sexually transmitted infection” [STI], “sexually transmitted disease” [STD], “venereal disease”, and “VD”)

Date of Publication: May 19, 2015
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Additional information on oropharyngeal human papillomavirus (HPV) infection related to cancer is addressed in the Oral Cancer Fact Sheet.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • Yes, if active infectious oral disease is suspected on the basis of history and/or examination. Warts are contagious.

Is medical consult advised?  

  • If patient/client is suspected to have warts (particularly oropharyngeal, facial, plantar [foot], or genital), refer to primary care provider (e.g., physician or nurse practitioner) for definitive diagnosis and management.1
  • If patient/client has oral and/or reproductive/systemic manifestations suggestive of an STI, refer to primary care provider  for follow-up, including diagnosis (e.g., visual inspection, biopsy, etc., for HPV infection) and management.
  • If the patient/client is suspected to have precancerous lesions or oral/oropharyngeal cancer, prompt medical/dental referral is indicated.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes, if active infectious oral disease is suspected on the basis of history and/or examination. Warts are contagious.

Is medical consult advised? 

  • See above. 

Is medical clearance required? 

  • Yes, if active infectious oral disease is suspected on the basis of history and/or examination. 

Is antibiotic prophylaxis required?  

  • No. 

Is postponing treatment advised?

  • Yes, if active infectious oral disease is suspected on the basis of history and/or examination. Instruct patient/client to reschedule dental hygiene appointment when the oral wart(s) or other oropharyngeal HPV infection has been appropriately treated.2

Oral management implications

  • Mode of transmission: Usually through direct contact with infected skin or mucous membranes. Warts may be autoinoculated (e.g., by razors in shaving), and contaminated floors are often implicated in plantar warts. STI-related warts result from intimate interpersonal contact (oral-oral; oral-penile; oral-anal; oral-vulvar/vaginal; penile-vaginal; penile-anal), some of which can result in oral manifestations. The risk of HPV transmission during oral sex (fellatio, cunnilingus, and anilingus) is increased if there are small cuts in the mouth (e.g., from dental work; brushing or flossing before/after oral sex; gum disease; or sharp foods). Risk during oral sex is also increased if there are sores on the mouth or genitals caused by rough or prolonged oral sex or an STI such as herpes or syphilis; if the person receiving oral sex is menstruating; and if there is holding of semen, vaginal fluid, or menstrual blood in the mouth for a long time or if it is swallowed. Incubation period from time of HPV infection to appearance of warts ranges from 1 to 20 months, with 2 to 3 months being most common.
  • Dental hygienists play an important role in prevention and detection of HPV-related oral lesions, particularly those of oral cancer. Education regarding HPV vaccination and safe oral sex practices saves lives. Timely identification of precancerous and cancerous lesions leading to prompt medical/dental referral can also reduce patient/client morbidity and mortality.
  • Sex partners of patients/clients with STIs should be assessed by an appropriate healthcare professional (e.g., physician) and treated as appropriate. The presence of oral warts should prompt referral to a physician to rule out genital lesions in the patient/client the patient/client’s sexual partners.
  • To reduce acquisition and spread of oral cavity STIs, condoms or dental dams should be used for all oral-genital and oral-anal contact. Brushing or flossing of teeth should be avoided within 30 minutes of giving oral sex. 
  • Oral condylomata identified in children raises suspicion of sexual child abuse when nonsexual contact, autoinoculation from other sites, and maternal-fetal transmission have been ruled out3; dental hygienists should be familiar with their professional reporting obligations to the Children’s Aid Society. Additionally, palatal petechiae in children could be a sign of forced oral sex. 
  • While the presence of genital or other non-oral warts in a patient/client does not affect dental hygiene management, oral warts are contagious. Standard precautions apply during oral dental hygiene procedures, which is important to avoid finger/periungal (fingernail area) wart acquisition by the dental hygienist.
  • Dental hygienists with periungal or other warts on their hands should seek medical treatment to accelerate resolution and decrease viral transmission potential. 
  • Laser ablation of oral condylomata acuminata should involve high-speed evacuation to avoid inhalation of the virus-laden plume, which can lead to laryngeal condylomata. 
  • High-risk types of HPV are implicated in 60% to 70% of oropharyngeal cancers (OPC) in North America. These HPV-related cancers are mostly found in the lingual and palatine tonsils, the soft palate, and the base of the tongue. Oropharyngeal cancers due to HPV usually occur in younger and healthier people as compared to non-HPV associated OPC, which tends to occur in smokers and persons who consume significant quantities of alcohol. The number of oral sex partners is the major risk factor associated with OPC development.
  • HPV immunization greatly reduces rates of oropharyngeal infection by high-risk types, and emerging scientific opinion suggests this will translate into reduced incidence of HPV-related oropharyngeal cancers in the future. In order to prevent HPV-related oral/oropharyngeal cancer, dental hygienists can play a role in suggesting that unvaccinated patients/clients — both male and female, particularly those aged 9 to 26 years — speak with their primary care physician regarding possible immunization. Currently in Ontario, HPV vaccine is publicly funded for all female and male Grade 7 students.
  • In contrast to cervical cancer, HPV-associated OPC does not currently have an identifiable precursor stage that lends itself to screening and management.

Oral manifestations

  • HPV infection has a wide range of clinical manifestations in the oral cavity — and not just warts.
  • Verruca vulgaris, or the common wart, can be found in the oral cavity. It is usually white and most commonly found on the keratinized surfaces of the gingiva and palate.
  • Filiform warts, variants of the common wart, can manifest on the lips. They are elongated, pointed, and delicate lesions that may reach 1 cm in length.
  • Condylomata acuminata (STI-related/genital warts, often associated with HPV types 2, 6, and 11) occur orally on the ventral tongue, gingiva, labial mucosa, and palate. These lesions have small, finger-like projections, resulting in an exophytic lesion with a rough or cauliflower-like verrucous surface. They tend to be larger, more clustered, more diffuse, and more deeply rooted than HPV-associated squamous papilloma lesions; they tend to be pinker than, and generally not as well keratinized as, the verruca vulgaris.
  • Focal epithelial hyperplasia (associated with HPV types 3 and 32) manifests as multiple, painless, papillomatous nodular lesions located mostly on the labial and buccal mucosa. The pink or white nodules tend to be sessile (rather than pedunculated) with a cauliflower (rather than finger-like) appearance. The nodules may be more generalized in the oral cavity than other HPV-related lesions. Classically, this rare, benign, oral condition4 appears most often in children of certain ethnic groups, particularly in indigenous peoples of North, Central, and South America. However, increasingly FEH is being identified in other populations, including Caucasians.
  • HPV-related oral cancer and precancerous lesions have various presentations.
  • Although oral warts can occur in any individual regardless of HIV status, recurrence after treatment is uncommon except in the case of HIV-infected persons. HIV-associated oral warts can be large and multi-focal, resulting in aesthetic and functional problems.

Related signs and symptoms

  • HPV infection5 manifests as diverse skin and mucous membrane lesions. The common wart is a circumscribed, hyperkeratotic, rough-textured painless papule, which varies in size from a pinhead to large masses. Filiform warts are usually found on the eyelids, face, and neck, in addition to the lips. Laryngeal papillomas occur on the vocal cords and epiglottis of children (likely transmitted during passage of the infant in the birth canal) and adults, and occasionally become malignant.6 Flat warts are smooth and slightly elevated, usually occurring in multiple lesions varying from 1 mm to 1 cm, and may be hyperpigmented or hypopigmented; they generally occur on the face and legs, and they are more common in children and adolescents than in adults. Plantar warts (verruca plantaris) are flat, hyperkeratotic, and sometimes painful lesions on the soles of the feet. Hyperkeratotic warts are typically well-circumscribed, rough textured papules, which range from 2 mm to 1 cm; they can be found anywhere on mucocutaneous surfaces and often occur in groups. 
  • 75% of sexually active Canadians will have at least one sexually transmitted HPV infection at some time during their lives. Many infected persons never develop overt signs/symptoms, but they still carry the virus and can infect their sexual partners. If genital warts (condylomata acuminata) are visible, they may manifest as small, cauliflower-like bumps, alone or in clusters, on the vulva, cervix, anus, penis, or thighs.
  • In women, presumptive HPV infection of the cervix can be detected by the Papanicolaou (Pap) test by examining cervical cells under a microscope; direct HPV testing of cervical cells is an option in some jurisdictions. Oncogenic (potentially cancer-causing) types of HPV are the cause of most cervical, anal, and penile cancers. 
  • Warts usually regress spontaneously within months to years. Treatment of the affected person decreases the amount of wart virus available for transmission.

References and sources of more detailed information


Date: December 23, 2014
Revised: January 25, 2020; August 5, 2024


FOOTNOTES

1 Depending on the location and severity of the wart(s), treatment options include: application of topical peeling or blistering agents (e.g., salicylic acid, cantharidin, etc.); cryotherapy (e.g., liquid nitrogen); application of antineoplastic agents (e.g., 5-fluorouracil); injection of antineoplastic agents (e.g., bleomycin); laser therapy; curetting; and surgery. Removal of warts does not necessarily eliminate HPV infection; warts can reoccur if the virus is still present in the body.
2 In the case of oral condylomata acuminata, lesions may require surgical excision, chemical treatment, or laser ablation.
3 Clinically distinguishing oral condylomata acuminata from focal epithelial hyperplasia can be difficult.
4 Lesions usually spontaneously regress, but they may reappear with trauma. Surgical excision may be an option when the cosmetically objectionable. The household transmission of the HPV types responsible for FEH is thought to be via saliva, directly or indirectly.
5 Based on their potential to cause serious disease, HPV types are classified according to risk level. High-risk HPV is associated with an increased risk of developing cancer, particularly cervical, oropharyngeal, and/or head and neck. (Examples include types 16, 18, 31, 33, 45, 52, and 58.) Low-risk HPV is generally not associated with cancer causation but can cause benign lesions such as common warts and genital warts. (Examples include types 6 and 11.) Probable high-risk HPV types have limited data but show possible links to development of cancer, with further research being needed for definitive classification. (Examples include types 26, 53, 66.)
6 When HPV causes warts in the respiratory tract or throat, the lesions may be referred to as (recurrent) respiratory papillomatosis.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.