Oral Lesions and Candidiasis Quiz
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Questions and Answers

What are the categories of oral lesions based on etiology?

  • Congenital, Acquired, Cancerous, Non-cancerous
  • White, Red, Pink, Black
  • Bacterial, Viral, Fungal, Other
  • Hereditary, Reactive/Inflammatory, Infective, Idiopathic, Immune Mediated, Miscellaneous (correct)

    • Which of the following is a condition caused by Candida species?

  • Oral Hairy Leukoplakia
  • Oral Candidiasis (correct)
  • Median Rhomboid Glossitis
  • Lichen Planus

    • Acute pseudomembranous candidiasis is often painless.

    True (A)

    What is a common sign of denture-induced stomatitis?

    <p>A red, smooth area (D)</p> Signup and view all the answers

    What is the most common site for angular stomatitis?

    <p>The corners of the mouth</p> Signup and view all the answers

    Median rhomboid glossitis is always painful.

    <p>False (B)</p> Signup and view all the answers

    What is a major risk factor for candidal leukoplakia?

    <p>Smoking (C)</p> Signup and view all the answers

    What is the hallmark of chronic mucocutaneous candidiasis?

    <p>Defect in cell-mediated immunity</p> Signup and view all the answers

    Erythroplakia is a red lesion that is always benign.

    <p>False (B)</p> Signup and view all the answers

    Which of these methods is the gold standard for diagnosing leukoplakia and erythroplakia?

    <p>Biopsy (A)</p> Signup and view all the answers

    What is the most common treatment for oral candidiasis?

    <p>Topical antifungal medications (D)</p> Signup and view all the answers

    In what situation are systemic antifungal drugs often required for oral candidiasis?

    <p>Cases resistant to topical treatment (B)</p> Signup and view all the answers

    Leukoplakia is defined as "any white spot or patch, which cannot be clinically or pathologically diagnosed as any other defined lesion".

    <p>True (A)</p> Signup and view all the answers

    Which clinical variant of leukoplakia is associated with a high risk of malignant transformation?

    <p>Proliferative verrucous leukoplakia (A)</p> Signup and view all the answers

    What is the recommended treatment for verrucous carcinoma?

    <p>Surgical excision</p> Signup and view all the answers

    Squamous cell papilloma is often associated with a history of smoking.

    <p>False (B)</p> Signup and view all the answers

    Which of the following is NOT a clinical sign of malignant transformation in leukoplakia?

    <p>White color (A)</p> Signup and view all the answers

    Toluidine blue staining can help differentiate between dysplastic and normal cells in leukoplakia.

    <p>True (A)</p> Signup and view all the answers

    What is the recommended management strategy for leukoplakia with severe dysplasia?

    <p>Surgical excision (C)</p> Signup and view all the answers

    How is erythroplakia defined?

    <p>A red lesion of questionable risk that cannot be clinically or pathologically defined as any other known lesion</p> Signup and view all the answers

    Erythroplakia is often symptomatic.

    <p>True (A)</p> Signup and view all the answers

    What percentage of oral erythroplakias are dysplastic or malignant at the time of biopsy?

    <p>90% (B)</p> Signup and view all the answers

    The management of leukoplakia and erythroplakia is primarily based on the histologic findings of the biopsy.

    <p>True (A)</p> Signup and view all the answers

    Flashcards

    Oral Candidiasis

    A fungal infection of the oral cavity caused by Candida species, primarily Candida albicans. Commonly affects the young and elderly.

    Acute Pseudomembranous Candidiasis (Oral Thrush)

    A painless, soft, creamy plaque that can be wiped off with difficulty. Often associated with a bad taste or loss of taste.

    Acute Atrophic or Erythematous Candidiasis (Antibiotic Stomatitis)

    A condition that develops after long-term use of broad-spectrum antibiotics, especially tetracyclines. Characterized by a red and glazed mucosa with flecks of thrush.

    Denture Induced Stomatitis

    Most common on the upper denture. Red, painful area caused by the denture interfering with the cleaning action of saliva.

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    Angular Stomatitis (Angular Cheilitis)

    Inflammation of the corners of the mouth (commissures) characterized by fissures, erythema, and crusting. May be secondary to candidiasis.

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    Median Rhomboid Glossitis

    A red patch of atrophic papillae on the center of the tongue. Often asymptomatic, some patients experience pain or irritation.

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    Chronic Hyperplastic Candidiasis (Candidal Leukoplakia)

    Firm, white, leathery plaques or speckles on the oral mucosa, especially bilaterally in the commissural region of the buccal mucosa. Associated with smoking and a risk of malignant transformation.

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    Chronic Mucocutaneous Candidiasis (Secondary Candidiasis)

    A defect in cell-mediated immunity or iron deficiency. Two categories: syndrome-associated CMC and localized or diffuse.

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    Chronic Erythematous Candidiasis

    Red macules (spots) primarily on the hard palate, dorsum of the tongue, and soft palate. Often associated with HIV infection.

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    Idiopathic (True) Leukoplakia

    Painless, white patches or plaques on the oral mucosa that cannot be clinically or histopathologically defined as any other known lesion. Potentially malignant.

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    Risk Factors for Idiopathic Leukoplakia

    What are some risk factors that might predispose individuals to idiopathic leukoplakia?

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    Homogenous Leukoplakia

    Well-defined white patch. Uniform in color. Elevated, fissured, wrinkled surface. Leathery or dry, cracked mud-like palpation.

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    Speckled Leukoplakia

    Mixed red and white. Keratotic nodules on an atrophic red base. High risk of malignant transformation.

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    Verrucous Leukoplakia

    Thick with a papillary surface. Heavily keratinized. Clinically indistinguishable from verrucous carcinoma.

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    Proliferative Verrucous Leukoplakia (PVL)

    Extensive papillary plaques that may involve multiple mucosal sites. More prevalent in elderly females. High risk of malignant transformation.

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    Verrucous Carcinoma

    A rare, slow-growing tumor that does not readily metastasize but can invade and destroy deeper tissues. Has an excellent prognosis due to its indolent behavior.

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    Squamous Cell Papilloma

    Exophytic masses caused by HPV. Asymptomatic. Occur between ages 30-50, sometimes earlier. Most common on the hard palate and tongue. Treated with surgical removal.

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    Clinical Signs of Malignant Transformation in Leukoplakia

    Ulceration, bleeding, induration, and lymphadenopathy indicate what?

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    Diagnosis of Leukoplakia/Erythroplakia

    What is the gold standard for diagnosing leukoplakia or erythroplakia?

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    Management of Leukoplakia/Erythroplakia with Severe Dysplasia or Carcinoma

    What is the main management approach if a biopsy reveals severe dysplasia or frank carcinoma in leukoplakia or erythroplakia?

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    Erythroplakia

    Red, velvety area on the oral mucosa. Often asymptomatic. More common in elderly patients. High malignant transformation rate.

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    Topical Antifungal Medications for Oral Candidiasis

    What are the main topical antifungal drugs used to treat oral candidiasis?

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    First-Line Treatment for Oral Candidiasis (2016 IDSA Guidelines)

    According to the 2016 IDSA guidelines, what is the first-line treatment for oral candidiasis in patients with no critical illness?

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    Systemic Antifungal Medications for Oral Candidiasis

    What are the main systemic antifungal medication classes used to treat oral candidiasis?

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    When to Use Systemic Treatment for Oral Candidiasis

    When would systemic antifungal therapy be preferred for oral candidiasis?

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    Study Notes

    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

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