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Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 439-441

Surgical removal for khat inducible verruca vulgaris lesion of the oral mucosa

Department of Maxillofacial Surgery, College of Dentistry, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia

Date of Acceptance08-Sep-2018
Date of Web Publication6-Mar-2019

Correspondence Address:
Dr. G Gazal
Department of Maxillofacial Surgery, College of Dentistry, Taibah University, P.O. Box. 2898, Al Madina Al Munawara - 41311
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_357_18

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The harmful effects of khat chewing on the oral mucosa membrane are still uncertain. Verruca vulgaris (common warts) is a benign lesion of skin and mucous membranes and can be caused by human papillomavirus. The lesions are typically self-limited but may vary in size and number. The occurrence on the floor of mouth is extremely rare. To the best of our knowledge, there are few number of oral lesions reported in connection with khat users. This case report shows that the chronic khat chewing has contributed to the development of verruca vulgaris warts that were confined to the chewing side of the mouth. A rare case of verruca vulgaris of the floor of mouth occurring in a 27-year-old Yamani male is presented with a discussion on etiopathogenesis and the treatment methods. Verruca vulgaris must be remembered in the differential diagnosis of the floor of mouth lesions, and surgical treatment may provide satisfactory outcomes.

Keywords: Floor of mouth, human papillomavirus, khat, verruca vulgaris

How to cite this article:
Gazal G. Surgical removal for khat inducible verruca vulgaris lesion of the oral mucosa. Niger J Clin Pract 2019;22:439-41

How to cite this URL:
Gazal G. Surgical removal for khat inducible verruca vulgaris lesion of the oral mucosa. Niger J Clin Pract [serial online] 2019 [cited 2022 Nov 29];22:439-41. Available from:

   Introduction Top

The chewing habit of khat leaves (Catha edulis) can cause mucosal pathologies; however, there are few reports on the oral findings due to this habit.[1] In this case report, a case of verruca vulgaris associated with heavy khat chewing is presented. Although human papillomaviruses (HPVs) cause the most common sexually transmitted infection and are responsible for large number of cases with cervical cancer, it is still considered as an important risk factor for oropharyngeal and tongue cancer.[2] Several studies have demonstrated a connection between HPV and oral cancer, which has tremendous relevance in patient care, including treatment and prevention of disease.[3],[4],[5],[6]

   Case Presentation Top

A 27-year-old Yemeni male (camel shepherd) has been referred to the screening clinic in the Taibah Dental College, Al-Madinah Al-Munawarah for multiple teeth extraction under local anesthesia in the 5th-year dental students' clinic. This patient is a nonsmoker and chews khat 3 times a day for 5 h since he was 15 years old. Medically, the patient was fit and well and was not on any medication. Two years before presentation, the patient began feeling a small lump in his mouth. Clinical examination revealed that the patient has poor oral hygiene with generalized periodontitis [Figure 1]a, [Figure 1]b, [Figure 1]c. There was a painless, exophytic, sessile mass of 1.5 × 1.5 cm [Figure 2] on the right side of the floor of the mouth [Figure 3]. It was in the middle of the distance between the base of tongue and lower right second molar. The lesion was isolated, not indurated, or having an ulcerated area on mucosa membrane. There was no sign of lymph nodes adenopathy. Under local anesthesia, the lesion was excised totally using needle-tip electrocautery with preservation of safe surgical margins [Figure 4]. The patient did not have lesions elsewhere in the body. The orthopantomogram (OPG) revealed that the adjacent teeth were intact and not associated with dental pathology. Diagnosis of verruca vulgaris was confirmed by pathological investigation and polymerase chain reaction analysis which revealed HPV-4 DNA. Four months postoperatively, there were no recurrences or complications sequelae.
Figure 1: (a-c) Poor oral hygiene and generalized periodontitis as a result of khat chewing

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Figure 2: The size of the mass which is about of 1.5 × 1.5 cm

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Figure 3: Exophytic, sessile lesion on the right side of the floor of the mouth

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Figure 4: The site of surgery with preservation of safe surgical margins

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   Discussion Top

Various lesions may present on the floor of the mouth. The effect of khat on the oral mucosa membrane was reported by a few studies previously.[2],[3],[4],[5],[6] However, there is still lack of the evidence whether the khat can cause oral leukoplakia or not. It must constantly be kept in mind that early carcinoma frequently appears as an area of erythroplasia, as 75–90% of lesions prove to be carcinoma/carcinoma in situ or are severely dysplastic.[4],[5] The incidence of malignant change is 17 times higher in erythroplasia than in leukoplakia.[6] Several studies have reported that khat chewing is considered as a harmful activity on health. Many different compounds are found in khat including alkaloids, terpenoids, flavonoids, sterols, glycosides, tannins, amino acids, vitamins, and minerals. The major pharmacologic and toxic effects come from the phenylalkylamines and the cathedulins.[7] The major effects of khat include those on the gastrointestinal system and central nervous system but also affect the cardiovascular, respiratory, endocrine, and genitourinary systems.[7],[8] The effects on the central nervous system resemble those of amphetamine with differences being quantitative.[8] The main toxic effects include increased blood pressure, tachycardia, insomnia, anorexia, constipation, general malaise, irritability, migraine, and impaired sexual potency in men.[9] Since this is a major social issue particularly in East Africa, raising awareness with the general public, in terms of the harmful effects of khat chewing,[5],[6],[7],[8] can be accomplished via appropriate communication strategies by using printed materials and electronic media.[8]

The clinical differential diagnosis of this case included verrucous leukoplakia, verrucous carcinoma, candidiasis (speckled white-on-red appearance), and squamous papilloma. Microscopically, the histopathological report showed that the lesion is verruca vulgaris (common viral wart), and no sign of atypia was seen.

There are two possible accounts for the explanation of the effects of khat chewing on the rapid onset of the oral viral infection. First, verruca vulgaris is a virus-induced neoplasm of the skin caused by a human papilloma virus. According to Halboub et al.,[10] khat chewing causes stomatitis that might be secondarily infected. It also causes periodontitis, teeth discoloration, and xerostomia.[9] So, the frictional trauma caused by the khat chewing might create rough areas in the oral mucosa, which in turn produce rapid proliferation of viruses.

Second, chronic khat chewing and the chemical composition of khat cause frictional keratosis with severe corrugation.[1],[3],[7],[10] The corrugation can be as a result of absorption of irritating substances of khat and continuous stretching of the oral mucosa collagen fibers during chewing sessions. These corrugations will form a resort to the increasing number of human papilloma viruses. The viral infection will aggravate the intracellular inflammation reaction, and as a consequence, enlargement in the size of the lesion will occur.[8],[9],[10]

   Conclusion Top

Chronic khat chewing has contributed to the development of verruca vulgaris warts that were confined to the chewing side of the mouth. Surgical excisional is the choice to eliminate such lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflict of interest

There are no conflicts of interest.

   References Top

Wabe NT. Chemistry, pharmacology, and toxicology of khat (Catha edulis forsk): A review. Addict Health 2011; 3:137-49.  Back to cited text no. 1
Muñoz N, Bosch FX, de Sanjosé S, Herrero R, Castellsagué X, Shah KV, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 2003;348:518-27.  Back to cited text no. 2
Gillison ML, D'Souza G, Westra W, Sugar E, Xiao W, Begum S, et al. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst 2008;100:407-20.  Back to cited text no. 3
Ural A, Arslan S, Ersöz S, Değer B. Verruca vulgaris of the tongue: A case report with literature review. Bosn J Basic Med Sci. 2014;14:136-8.  Back to cited text no. 4
Al-Maweri SA, Warnakulasuriya S, Samran A. Khat (Catha edulis) and its oral health effects: An updated review. J Investig Clin Dent 2018;9. doi: 10.1111/jicd.12288.  Back to cited text no. 5
Al-Akhali MS, Al-Moraissi EA. Khat chewing habit produces a significant adverse effect on periodontal, oral health: A systematic review and meta-analysis. J Periodontal Res 2017; 52:937-45.  Back to cited text no. 6
Atlabachew M, Combrinck S, Viljoen AM, Hamman JH, Gouws C. Isolation and in vitro permeation of phenylpropylamino alkaloids from Khat (Catha edulis) across oral and intestinal mucosal tissues. J Ethnopharmacol 2016;194:307-15.  Back to cited text no. 7
Marway R. Oral health: The destructive effects of khat. Br Dent J 2016;221:2.  Back to cited text no. 8
Lukandu OM, Koech LS, Kiarie PN. Oral lesions induced by chronic Khat use consist essentially of thickened hyperkeratinized epithelium. Int J Dent 2015. doi: 10.1155/2015/104812.  Back to cited text no. 9
Halboub E, Dhaifullah E, Abdulhuq M. Khat chewing and smoking effect on oral mucosa: A clinical study. Acta Medica (Hradec Kralove) 2009;52:155-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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