FOCAL EPITHELIAL HYPERPLASIA (HECK'S DISEASE)

P. BRADNUM, B.D.S., F.D.S.R.C.S.(Eng.)

Newcastle General Hospital

FOCAL epithelial hyperplasia was first reported by Archard et al. (1965) who des- cribed the condition in Nor th American Indians. T h e disease is characterised by mult iple elevated lesions on the oral mucosa.

CASE R E P O R T

The patient, a male Scottish lorry driver, aged 36, was referred in 1962 for the re- moval of fibromas of his cheeks. His general health was excellent, and there was no history of previous illnesses apart from the normal childhood ailments. He had never been abroad except for one year in Germany while serving in the Army.

FIGS. I, 2~ 3 and 4 Fig. I.--Cheek after removal of fibrous hyperplastic lesion showing multiple

nodules inside cheek and on mandibular ridge.

Fig. 2.--Photograph of plaster model cast from an alginate impression show- ing 6--3 / area. Multiple small evelations present on alveolar ridge.

Fig. 3.--Relaxed lower lip showing multiple nodular lesions.

Fig. 4.--Stretched lower lip showing lesions less apparent. Multiple lesions can be seen on lower alveolus.

In addition to an area of fibrous hyperplasia at each angle of the mouth due to cheek- biting, there were multiple small elevations on the oral mucosa (Fig. I). The alveolar ridges, cheeks, tongue and the mucosa of the lower lip were covered with small, sessile

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FOCAL EPITHELIAL HYPERPLASIA (HECK'S DISEASE) I3i

nodules, some of which were confluent. Both alveolar ridges were affected, the maxillary ridge more so than the mandibular, and the lesions were more numerous in the anterior regions (Fig. 2).

The lower lip was most severely affected, and when relaxed it appeared to be covered wi th villi; on stretching the lip the lesions became less noticeable (Figs. 3 and 4)- The anterior part of the palate was affected, but there were no lesions on the soft palate, floor of mouth or oropharynx.

The nodules were between I and 2 ram. in diameter and the same colour as the normal mucosa. All the lesions were symptomless and there was no evidence of indura- tion or inflammation.

Numerous haematological and biochemical tests were performed, the results of which were all within normal limits.

H i s to logy . T h e histology of the two larger lesions showed the typical appear- ance of fibrous hyperplasia due to chronic irritation.

FIG. 5 FIG. 6 Fig. 5.--Histological appearance of a nodule showing acanthosis and para- keratosis. The rete pegs are thickened but the basement membrane is

normal. Very slight polymorphonuclear infiltration. H and E. x 8o.

Fig. 6.--Section showing hydropic degeneration of prickle cell layer with loss of nuclei. Very slight inflammatory reaction. H and E. x 80.

Multiple biopsies of the other small lesions showed changes in the epithelium only (Figs. 5 and 6). All sections showed acanthosis, and very often parakeratosis. The rete pegs were thickened but the basement membrane appeared normal. T h e underlying corium was normal, with only minimal evidence of polymorphonuclear infiltration.

Some lesions showed hydropic degeneration of the prickle cell layer with loss of nuclei, but even in these there was little inflammatory reaction.

As the patient had common warts on his hands and nose it was thought the oral lesions may have been due to auto-innoculation, but this was excluded by the histological appearance, as was multiple neurofibromata and epiloia.

The condition has remained unchanged over the past seven years, and in spite of the irregular mucosal surface dentures are well tolerated.

D I S C U S S I O N

Since first reported by Archard et al. (1965) there have been seven further reports of the disease, affecting approximately 50 patients (Witkop & Niswander, I965; Het twer & Rodgers, 1966; Waldman & Sheldon, r968; Phillips & Williams,

132 BRITISH JOURNAL OF ORAL SURGERY

1968; Fischman, 1969; Schock, 1969; and Decker & de Guzman, 1969). These case reports relate to the natives of Brazil, Mexico, Peru, Paraguay and Bolivia. Most patients have been under the age of puberty, and in some of them the lesions have disappeared over a 12 to IS month period. The oldest recordedcase (Waldrnan & Shelton, 1968) is in a 56-year-old Caucasian woman; and the youngest in a three- year-old North American Indian (Archard et al., 1965).

The aetiology is unknown, and though the lesions resemble those that are associated with a virus, attempts to grow a virus were unsuccessful. No dietary or other common factor has been discovered, and the sex distribution is equal.

The condition appears to be completely benign, causes no symptoms, and does not prevent the wearing of dentures

SUMMARY

Focal epithelial hyperplasia is a benign disease of unknown aetiology, char- acterised by multiple small, symptomless, elevated nodules on the oral mucosa. It has previously only been reported in the New World.

ACKNOWLEDGEMENTS

I wish to thank Professor I. Rannie of the Oral Pathology Department, Newcastle Dental Hospital, for his help and for the photomicrographs and Mr. B. Hill of the Photographic Department for the other illustrations.

REFERENCES

ARCHARD, H. O., HECK, J. W. & STANLEY, H. R. (1965). Oral Surgery, Oral Medicine & Oral Pathology, 20, 201.

DECKER, W. G. & DE GUZMAN, M. N. (1969). Oral Surgery, Oral Medicine & Oral Patho- l%‘Y, 27, 1.5.

FISCHMAN, S. L. (1969). Oral Surgery, Oral Medicine & Oral Pathology, 28, 389. HETTWER, K. J. & RODGERS, M. S. (1966). Oral Surgery, Oral Medicine & Oral Pathology,

22, 466. PHILLIPS, H. & WILLIAMS, A. (1968). Oral Surgery, Oral Medicine & Oral Pathology,

26, 619. SCHOCK, R. K. (1969). Oral Surgtzy, Oral Medicine & Oral Pathology, 28, 598. WALDMAN, G. H. & SHELTON, D. W. (1968). Oral Surgery, Oral Medicine & Oral Patho-

logy, 26, 124. WITKOP, C. J. & NISWANDER, J. D. (1965). Oral Surgery, Oral Medicine & Oral Pathology,

20, 213.