Oral Lesions and Candidiasis Quiz

White and Red Oral Lesions

• Oral lesions are categorized by etiology (cause)

Classification

• Hereditary
• Reactive/inflammatory
• Infectious
• Immune-mediated
• Idiopathic
• Miscellaneous

Infectious White and Red Lesions

• Oral hairy leukoplakia
• Oral candidiasis

Oral Candidiasis

• Primary Oral Candidiasis
  • Acute: pseudomembranous (thrush), acute atrophic/erythematous (antibiotic stomatitis)
  • Chronic: erythematous, pseudomembranous, hyperplastic, angular cheilitis, denture stomatitis, median rhomboid glossitis, keratinized primary lesions with Candida, lichen planus, lupus erythematosus
• Secondary Oral Candidiasis: oral manifestations of systemic mucocutaneous candidiasis (CMC)

Etiology of Oral Candidiasis

• Fungal infection caused mainly by Candida albicans
• Occurs in extremes of age (very young and very old)
• Associated with factors like xerostomia, denture wearing, long-term antibiotic/steroid therapy, immunosuppressed patients (e.g., HIV/AIDS), chemotherapy/radiotherapy to the head and neck, uncontrolled diabetes, or cancer (e.g., leukemia, lymphoma)

Acute Candidiasis (Oral Thrush)

• Painless
• Soft, friable, creamy plaque
• Whitish pseudomembrane composed of sloughed epithelial cells, debris, fungal mycelium, and neutrophils loosely attached to the oral mucosa
• Can be wiped off with difficulty
• Associated with bad taste/loss of taste

Diagnosing Oral Candidiasis

• Smear and Periodic acid Schiff (PAS) stain to detect Candida hyphae
• Biopsy to reveal hyperplastic epithelium, inflammatory cells, and edema

Acute Antibiotic Stomatitis

• Follows broad-spectrum antibiotic overuse (e.g., tetracycline)
• Linked to xerostomia (e.g., Sjogren's syndrome) and drug-induced conditions
• Mucosa is red, glazed, and speckled with thrush-like flecks
• Tongue lesions appear as depapillated areas

Chronic Candidiasis: Denture Stomatitis

• Common in upper dentures
• Due to ill-fitting dentures hindering the cleansing action of saliva
• Primarily observed in denture wearers with poor hygiene or continuous denture use
• Presents as a painless red area, possibly associated with angular cheilitis

Chronic candidiasis: Clinical Manifestations

• Mildest form appears as small, asymptomatic red spots on posterior palatal mucosa
• Worsening condition leads to large confluent crimson red areas
• Later stages involve palatal mucosa hyperplasia; producing a red, pebbly appearance characteristic of papillary hyperplasia

Management of Oral Candidiasis

• Topical antifungal drugs, sterilization of dentures with fungicide or chlorhexidine
• Maintaining good oral and denture hygiene, soaking dentures overnight in water with a denture cleaner

Angular Stomatitis (Angular Cheilitis)

• Inflammation of oral commissures (corners of the mouth) with fissures, erythema, and crusting
• Caused by leakage of infected saliva containing Candida
• Factors include low vertical dimension, loss of upper lip support, and ptyalism
• May be secondarily infected with bacteria
• Associated with other candida types

Predisposing Factors for Angular Stomatitis

• Loss of occlusal height
• Deficiencies in nutrition (iron, vitamin B6, B12, folic acid)
• Poorly controlled diabetes
• HIV and immunosuppressed patients
• Mixed candidal and bacterial infection (e.g., staphylococcus aureus, streptococci)
• Mycology (nystatin+triamcinolone) is effective in the treatment of angular cheilitis
• Other topical antifungals may be used (e.g., ketoconazole, miconazole, clotrimazole)

Median Rhomboid Glossitis

• Red patch of atrophic papillae on the central dorsal tongue
• Often asymptomatic
• Some patients experience persistent pain or irritation

Etiology of Median Rhomboid Glossitis; Debatable

• Could be developmental defects from incomplete descent of tuberculum impar, trapping a portion between fusing lateral tongue halves
• Some suggest chronic fungal infection, responding to antifungals (diagnosis ex juvantibus)

Chronic Hyperplastic Candidiasis (Candidal Leukoplakia)

• Firm, white, leathery plaques, sometimes speckled
• Usually bilateral on commissural regions of buccal mucosa; can involve cheeks, lips, tongue, and palate
• Candida invades deeper mucosa, leading to a proliferative response
• Associated with smoking; carries a risk of malignant transformation
• Treatment: topical antifungals for 2 weeks, biopsy if no resolution

Chronic Mucocutaneous Candidiasis (Secondary Candidiasis)

• Defect in cell-mediated immunity or iron deficiency
• Two categories:
  • Syndrome-associated CMC: familial (candidosis endocrinopathy syndrome), chronic (thymoma)
  • Localized (oral, skin, nails) and diffuse (widespread)

Chronic Erythematous Candidiasis

• Red macules, especially in HIV infection
• Typically found on the hard palate, dorsum of the tongue, and soft palate

Idiopathic (True) Leukoplakia

• Defined as a white lesion of questionable risk, not readily identifiable as any other known lesion; potentially malignant
• Requires biopsy for diagnosis, frequently showing hyperkeratosis (about 20% ), but potentially dysplasia
• Potential malignant lesion

Idiopathic (Risk Factors)

• Smoking, alcohol use (synergistic with smoking), HPV infection, ultraviolet radiation, candidal infection, genetic makeup, vitamin deficiencies (questionable)
• Age: mostly elderly
• Sex: more prevalent in males

Clinical Variants of Leukoplakia:

- Homogenous leukoplakia
- Speckled leukoplakia
- Verrucous leukoplakia
- Proliferative verrucous leukoplakia

Verrucous Leukoplakia

• Thick with papillary surface
• Heavily keratinized
• Commonly found in older patients
• Clinically indistinguishable from verrucous carcinoma

Proliferative Verrucous Leukoplakia (PVL)

• Extensive papillary plaque or multiple mucosal sites
• Prevalent in older females (60 years+)
• High rate of malignant transformation to squamous cell carcinoma (SCC)
• PVL is a long-term progressive condition, growing into multifocal disease with exophytic and proliferative features.
• High recurrence and malignancy rate. Total excision with free surgical margins is crucial, combined with long-term follow-up.

Differential Diagnosis of PVL

- Verrucous carcinoma
- Squamous cell papilloma

Verrucous Carcinoma:

• Rare, slow-growing tumor; primarily exophytic, doesn't metastasize
• Infiltrating, though less aggressive than other forms; low-grade, well-differentiated variant of oral SCC
• Excellent prognosis; indolent clinical behavior

Squamous Cell Papilloma

• HPV-related exophytic lesions
• Asymptomatic, commonly found in the 30-50-year age range (sometimes earlier)
• Common on hard palate and tongue
• Treatment usually involves surgical removal

Clinical Signs of Malignant Transformation

• Ulceration
• Bleeding
• Induration
• Lymphadenopathy

Diagnosis of Leukoplakia/Erythroplakia

• Tissue biopsy is the gold standard
• Toluidine blue staining; stains dysplastic/malignant cells; resists acetic acid
• Cytobrush technique; for obtaining full-thickness epithelial cells for cytologic examination
• Exfoliative cytology offers limited benefit in these conditions

Management of Oral Leukoplakia/Erythroplakia

• Determined by histologic findings
  • Hyperkeratosis and acanthosis without dysplasia: removal of causative factors (e.g., smoking/alcohol) and regular follow-up
  • Severe dysplasia or carcinoma: total surgical excision
  • Mild dysplasia: causative factor removal and regular follow-up

Erythroplakia

• Defined as a red lesion of questionable risk, not clinically or histopathologically classifiable as other lesions; potentially malignant
• Idiopathic but potentially linked to leukoplakia risk factors
• Usually asymptomatic
• Commonly found on the ventral tongue, floor of the mouth, palate, and tonsils, typically in older patients (60-70 years old)
• High rate of malignant transformation (over 90% of detected cases are dysplastic/malignant during biopsy)

Topical Antifungal Drugs

• Nystatin oral suspension (mouthwash 4 times daily)
• Clotrimazole lozenges (4 times daily)
• Ketoconazole, miconazole (e.g., Daktarin oral gel; topical cream/ointment)
• Use dependent upon the condition

Systemic Antifungal Drugs

• Echinocandins (e.g., caspofungin, micafungin, anidulafungin) recommended as initial therapy
• Fluconazole (oral or IV) an alternative initial treatment for non-critically ill subjects
• Amphotericin B as a last resort for treatment intolerance or resistance to other anti-fungals