Focal epithelial hyperplasia: a surveyof two isolated communities in theCape Province ot South AtricaV n Wyk CW, Harris AMP; Focal epithelial hyperplasia; a survey of two isolatedommunities in the Cape Province of South Africa. Community Dent Oral Epidemi-

ol 1987; 15: 161-3.

Abstract - The aims of this study were to determine the distribution of focal epithelialhvoerplasia (FEH) among Cape Coloured communities, and whether a family

nection could be traced. Two isolated communities near Cape Town were selectedH it was attempted to examine as many population members as possible. After

. g established that one community had a comparatively high prevalence of FEH,second visit was undertaken to determine whether a familial distribution existed.

Six hundred and fifty-six people and 130 households were examined in the aboveommunity and 486 people in the second. The median ages of the two communities

re 18 6 and 18.4 yr respectively. Both age and sex distributions of the two popula-t ons did not differ significantly. A significant difference in the prevalence of FEH

as found between the two communities. Ninety-seven cases (14.8%) were diagnosed• the first and 21 cases (4.3%) in the second community (P<0.05). FEH occurredn all age groups and both sexes. Lesions occurred mostly on the mucosae of thelower and upper hps and in the gingiva. No definite familial distribution could beestablished.

Werner van Wyk and Angela HarrisResearch Group in Dental Epidemiology,Medical Research Council, LIniversity otStellenbosch. Tygerberg. South Africa

Key words; focal epithelial hyperplasia; oralmucous membrane

C. W. van Wyk. Department of Oral Pathology.Dental Faculty, University of Stellenbosch,Private Bag XI, Tygerberg 7505, South Africa

Accepted for publication 24 October 1986

The term focal epithelial hyperplasia(FEH) was introduced by Archard et al.(I) in 1965 to describe "multiple discretepapules occurring at various sites on theoral mucosa, but most commonly thelower lip". However, HHLMS had notedsimilar lesions in Greenland Eskimos in

1894 (2).Many reports show that FEH is more

common among certain populationgroups. Prevalences ranging from 3% to36% have been described for GreenlandEskimos (2). Among the South AmericanIndians the prevalences are more moder-ate (less than 3.5% (3-5)), except for anunusually high prevalence of 34% amongschoolchildren in Venezuela (2). Only iso-lated cases have been described amongCaucasians in America, Europe and theMiddle East (6-8), among American Ne-groes (9) and among aborigines in Aus-traUa and Polynesia (10, 11).

In 1975 VAN WYK (12) diagnosed 76cases of FEH during an oral health sur-vey of various Cape Coloured communi-ties in the Cape region, and found a par-ticularly high prevalence (8.4%i) in cer-

tain secluded communities. The CapeColoureds are a mixture of ethnic el-ements, mainly Caucasian, Hottentot(Khoi) and Negro, and in some in-stances, Asian. They have a westernizedway of living.

Newer evidence associates the prob-able cause of the disease to the papillomavirus (13), designated as type 13 (14).There is still, however, some uncertaintyabout how the infection is transmitted,the duration of the ineubation period andwhy certain communities seem to be af-fected more than others.

The literature also suggests a directrelationship between prevalence and de-gree of mixture of Caucasian inllucnce inthe population. This theory, i.e. a higherprevalence of FEH in people with lessCaucasian heredity, suggests that a gen-etic factor may also be linked with FEH(2, 4). There seems to be a strong familyrelated incidence, although no hereditarycases have been reported (1, 5, 15).

The aims of this study were to deter-mine whether there is an unequal distri-bution of this disease between Cape Co-

loured communities, and whether a fam-ily connection can be traced.

Material and methods

Two Cape Coloured communities wereselected on the basis of both being inisolated areas, both having a total pop-ulation of about 1000 members and bothbeing located in the North-WesternCape. One community, Garies, about 500km north of Cape Town, was previouslyinvestigated (12). The seeond communityselected was Wuppertal, about 300 kmnorth of Cape Town. Examinations werecarried out in both communities in thesummer season.

It was attempted to examine all peoplein the community. Schoolgoing childrenwere examined at school, seated on ahousehold chair, and the adults wereexamined at their homes or places ofwork. The examinations were done usingwooden spatulas, in direct sunlight orby making use ofa strong torch. Wherepossible, lesions were photographed on35 mm coloured transparencies.

162 VAN W Y K AND H A R R I S

Fig. 1, Age distributions of the two communi-ties.

.•••I

W 20 30 40 50 60 70 80

AGE onoup

Fig. 2. Prevalence of FEH in the two eom-munities.

Lesions were diagnosed as FEH if theywere raised, papular lesions, similar incolour to the adjacent mucosa. Wherelesions occurred on lining mucosa theytended to disappear when the mucosawas stretched. The lesions were painless.Lesions not diagnosed as FEH were ped-unculated lesions, white lesions and anylesions with a cauliflower-like surface.

After it was established that Garieshad a comparatively high prevalence ofFEH, a second visit was undertaken todetermine whether there was a family dis-tribution of cases. It was attempted toexamine all households, and all membersof such households. A household was de-fined as all persons who lived together inthe same abode.

The chi-square test and Fisher's exacttest were used to test for statistically sig-nificant differences among groups and Pvalues smaller than 0.05 were regarded-

as significant. To test for mutual depen-dence between the number of FEH casesper household and household size theSpearman Rank Correlation test was ap-plied. The z statistic was used to testhypotheses about population pro-portions.

ResultsThe population

Garies - It was possible to examine 130households and 656 people, of which 294were men (45%) and 362 (55%) women.Their age distribution varied from 2 yrto 88 yr, with a median age of 18.6 yr.

Wuppertal- Four hundred and eighty-six people were examined, 283 (58.2%)women and 203 (41.8%) men. The agedistribution of the population variedfrom 3 years to 83 yr, with a median ageof 18.4 yr.

The populations of Garies and Wup-pertal by age showed a relatively similardistribution (P>0.05, Fig. 1). More than50% of the populations were youngerthan 30 yr of age and sex distributionbetween the towns did not differ signifi-cantly (P>0.05), but in both places therewere relatively more women than men.It was not possible to examine all adultmen, as many worked elsewhere.

Focal epithelial hyperpiasia

Ninety-seven cases (14.8yo) of FEH werefound at Garies and 21 eases (4.3%) atWuppertal (i'<0.001).

Age distribution - Age adjusted valuesfor positive cases indicate that FEH oc-curred in all age groups, with no predilec-tion for any specific age groups (P>0.05,Fig. 2).

Sex dislribitlion - There were no sig-nificant differences between the preva-lence rates of FEH for men and womenin both communities (/'>0.05). Garieshad a significantly higher occurrence ofFEH in men than did Wuppertal, the

Table 1. Anatomical position of lesions

Garies

Wuppertal

Muco.salower lip

47(35.3%)

5(17.2%)

Mucosaupper lip

35(26.3%)

7(24.2%)

Buccalmucosa

22(16.5%)

5(17.2%)

Commis-sures

14(10.5%)

4(13.8%)

Gingiva

8(6.0%)

8(27.6%)

Tongue

6(4.5%)

0

Palate

1(1.08%)

0

n

133

29

MEN WOMEN

-294 362

MEN WOMEN

N-203 283

n-4a 49 " " " IO

Fig. 3, Sex distribution of positive cases ofFEH in the two communities.

3 4 5 6 7 B 10 11 T2~l TT

NUMBER IN HOUSEHOLD

Fig. 4. Relationship between number of casesand household size (Garies). Scatter diagranishows that there is a low correlation betweennumber of FEH eases per household andhousehold size.

prevalence rates being 16.3% and 2.5%respectively (P< 0.001). A similar trendwas evident for women, where the re-spective frequencies for Garies and Wup-pertal were 13.5% and 5.7% (P<0.001)The occurrence of FEH in womenshowed a more even distribution of casesthrough all the age groups (Fig. 3).

Anatomical distribution — In Garies sig.nificantly more lesions occurred on themucosae of the lower and upper lips thai)at other sites, whereas the lesions at Wup-pertal preferentially occurred on the giiv-giva and upper lip (P<0.05. Table 1).Although more lesions occurred on thelower lip than on the upper lip, the differ-ence between these two proportions wasnot significant (P>0.05).

Familial distribution - Of the 130households examined in Garies, 58(44.6%) had one or more positive case(s).Twenty-four of these households (44.4%)had only one positive case; in most in-stances this was a child (Fig. 4). In manyinstances it was virtually impossible todetermine family relationships, as differ-ent families lived together under the same.

Focal epithelial hyperplasia in South Africa 163

roof and little distinction was made be-tween members of such a household.There was a significant but low corre-lation between the number of FEH casesper household and household size(Spearman r = 0.3408, P = 0.0042).

Discussion

The high prevalence of FEH in Garies,14.8%, iTiay be regarded as the trueprevalence as a large proportion of thecommunity were examined. The resultsof the Wuppertal survey indicate that,although this area has a lower prevalenceof F E H than Garies (4.3%), FEH is notnon-existent there. Both these prevalencerates fall within the range of rates de-scribed for Eskimos, between 10% and20%, and South American Indians, 3.5%(2). The rural Cape Coloured populationcan therefore be aecepted as anotherpopulation group with a relatively highprevalence of FEH.

The difference in occurrence rates be-tween the two populations is difficult toexplain. From the general appearancethere could be different dietary and so-ciologic influences, but these would haveto be verified by special investigation.

In this study there were no statisticallysignificant differenees between the ageand sex distributions for FEH in the twocommunities. There was a tendency forrelatively more women than men to haveFEH in the age group younger than 20yr but in the age group older than 20 yrthe trend was reversed and relativelymore men had the disease. Particularlyhigh prevalences occurred in the men inGaries in age groups 30-40 yr and 50-70

yr. These findings do not differ markedlyfrom other reports. PRAETORtus-CLAUSEN(2) reported that lesions are relativelymore prominent in South American Indi-ans younger than 18 yr old but in Eski-mos a higher prevalence exists in olderage groups. It therefore seems that thisdisease has no specific sex or age distri-bution.

The highest frequencies of lesions werelocated on the lower lip, upper lip andgingiva. Most publications report FEH

involvement of the lower lip (2). Thisoral distribution of lesions may indicatetransmission of the etiologic agent byoral contact.

Results obtained from our survey donot indicate a specific family pattern.However, as so little is known about themode of infection, the incubation periodand the natural history of the disease,no definite conclusion should be reached.An in depth longitudinal study may verywell indicate the opposite.

References1. ARCHARD HO, HECK JW, STANLKY JR. Foeal epithelial hyperplasia: An unusual oral mucosal

lesion found in Indian children. Orat Surg 1965; 20: 201-12.2. PRAETORIUS-CLAUSEN F. Geographical aspeets of oral focal epithelial hyperplasia. Pathot

Microbiol 1973; 39: 204-13.3. FiSHMAN SD. Focal epithelial hyperplasia; ease reports from Paraquay and Peru. Oral Surg

1969; 25.- 389-93.4. WITKOP CJ, NISWANDER JD. Foeal epithelial hyperplasia in Central and South American

Indians and Landinos. Orat Surg 1965; 20: 213-7.5. GoMHZ A, CALLE C , ARCILA G , PINDBORG JJ. Focal epithelial hyperplasia in a half-breed

family of Colombians. J Am Dent A.s.mc 1969; 79: 663-7.6. AxELL T, HAMMARSTROM L, LARSON A. Foeal epithelial hyperplasia in Sweden. Acta Odontot

Sram/198I;.?9. 201-8.7. BuCHNER A, MASS E. Foeal epithelial hyperplasia in an Israeli family. Orat Surg 1973; 36:

507-11.8. PiLGARD G. Focal epithelial hyperplasia. Report of nine cases from Sweden and review of

the literature. Orat Surg 1984; 57: 540-3.9. SWEET J B , LEE WB, TOPPING JW. Focal epithelial hyperplasia with sarcoidosis in an Amer-

ican Negro. J Oral Surg 1973; 31: 473-6.10. PHILLIPS H , WILLIAMS A. Focal epithelial hyperplasia. Report o f a case. Oral Surg 1968;

26: 619-22.11. HETTWER K J , RODGERS MS. Focal epithelial hyperplasia (Heek's disease) in a Polynesian.

Orat Surg 1966; 22: 466-70.12. VAN WYK CW. Foeal epithelial hyperplasia of the mouth: reeently discovered in South

Africa. Br J Dermatot \911; 96: 381-8.13. LuTZNER M, KuiTHR R, BLANCHET-BARDON C , CROISSANT O. Different papillomaviruses as

the causes of oral warts. Areh Dermatol 1982; 118: 393-9.14. PFISTER H , HETTICH I, RUNNE tJ, GISSMANN L , CHILF G N . Characterization of human

papillomavirus Type 13 from focal epithelial hyperplasia Heck lesions. J Virol 1983; 47:363-6.

15. ScHOCK RK. Familial focal epithelial hyperplasia. Report o fa ease. Otal Surg 1969; 25.'598-602.