Oral Candida albicans (Oral Candidiasis)

Signs & Symptoms

1. Pseudomembranous Candidiasis (Thrush)

• White fungal plaques on any oral mucosal surface
• Plaques can be rubbed off, leaving a red or bleeding base
• Usually of relatively short duration

2. Erythematous (Atrophic) Candidiasis

• Chronic erythema and atrophy of filiform papillae on the dorsal tongue
• Patchy, ill-defined erythema on the palate, tongue, or buccal mucosa
• Oral mucosal burning and sensitivity to spicy/acidic foods
• Common in patients with chronic salivary hypofunction (e.g., Sjögren syndrome, anticholinergic drug effects)
• In denture wearers: erythema confined to the denture-bearing area (denture stomatitis)

3. Hyperplastic Candidiasis (Candidal Leukoplakia)

• White lesions that do not rub off (fungal hyphae within hyperkeratotic epithelium)
• Most often on the anterior buccal mucosa or tongue

Associated: Angular Cheilitis

• Erythema or crusting at the labial angles (corners of mouth), usually with concurrent intraoral candidiasis

Predisposing Factors

• Suppression of bacterial flora by systemic antibiotics
• Chronic salivary hypofunction / xerostomia
• Uncontrolled diabetes mellitus or anemia
• Immunosuppression (especially HIV infection)
• Ill-fitting or infected removable dentures

Treatment Plan — Oral Candidiasis

First-line (patients with normal salivary flow):

• Fluconazole: 200 mg on day 1 (loading dose), then 100 mg daily for 2 weeks

Patients with severe salivary hypofunction (xerostomia):

• Systemic antifungals may be ineffective (insufficient saliva to carry the drug to mucosa)
• Use vaginal nystatin tablets dissolved slowly in mouth (15–20 min) twice daily × 2 weeks
• Or miconazole tablets 50 mg daily dissolved slowly in mouth
• Both contain little to no cariogenic carbohydrates (safe for teeth)
• Patients need frequent sips of water to aid tablet dissolution

Note: Standard oral antifungal troches/pastilles contain sucrose/glucose and must be avoided in xerostomic patients with natural teeth due to high caries risk.

Denture-associated candidiasis:

• Antifungal treatment as above plus effective disinfection of the denture

Angular cheilitis:

• Topical clotrimazole 0.75% cream to the angles of the mouth, combined with systemic or intraoral antifungal treatment

Treatment end point:

• Mucosal burning ceases
• Patient tolerates acidic/spicy foods
• Filiform papillae on dorsal tongue return to normal
• Recovery takes 2–12 weeks depending on salivary production and compliance
• Recurrence is common in patients with chronic salivary hypofunction or immunosuppression → long-term noncariogenic topical antifungal maintenance may be required

Oral Lichen Planus

Signs & Symptoms

Clinical Forms:

• Delicate white keratotic striae (Wickham's striae) that intersect and arborize — lacy/annular pattern
• Bilaterally symmetric distribution over buccal mucosa (hallmark location)
• May extend to tongue, mucobuccal folds, attached gingiva, vermilion lip
• Generally asymptomatic

• Smooth, macular to slightly elevated and minimally fissured white plaques
• May mimic leukoplakia; bilaterality helps differentiate

• Faint white striae with thinned, reddened (erythematous) mucosa
• Most commonly affects attached gingiva
• Loss of normal pink, stippled surface → glossy, edematous, erythematous appearance
• Tender, bleeds easily on contact → impairs oral hygiene → accumulation of plaque

• Central, painful ulcerations, usually superficial but can be deep
• Ulcers covered by a pseudomembrane or adherent fibrinous plaque
• Typically multifocal — lateral/ventral tongue and buccal mucosa
• Peripheral white striae visible at ulcer margins
• Lesions heal and recur in variable patterns over time

• Bullae ranging from a few mm to >1 cm
• Transient — on rupture, painful ulceration results
• Predominantly over posterior/inferior buccal mucosa

Key Diagnostic Feature:

• Bilateral symmetry is characteristic and helps distinguish OLP from traumatic or malignant lesions

Treatment Plan — Oral Lichen Planus

Asymptomatic Reticular/Plaque Form:

• No treatment required; observation and monitoring

Symptomatic / Erosive / Atrophic Form:

• Topical corticosteroids (mainstay of therapy):
  • High-potency agents: fluocinonide gel, clobetasol gel/ointment applied to lesions
  • Triamcinolone acetonide in orabase for accessible lesions
• Intralesional corticosteroid injections for refractory focal lesions

• Systemic corticosteroids (prednisone) for severe, widespread, or rapidly progressing disease
• Tacrolimus 0.1% ointment (topical calcineurin inhibitor) — effective for erosive OLP, especially when steroids are contraindicated
• Cyclosporine oral rinse or systemic

• Systemic immunosuppression (as per Goldman-Cecil Medicine) targeting the underlying T-cell–mediated process

Adjunct Measures:

• Identify and eliminate lichenoid drug reactions (NSAIDs, ACE inhibitors, antimalarials, thiazides, beta-blockers, gold) by medication review
• Treat concurrent candidiasis (frequently superimposed on atrophic/erosive OLP)
• Maintain meticulous oral hygiene; manage secondary bacterial plaque accumulation
• Regular follow-up: OLP carries a low but real risk of malignant transformation to oral squamous cell carcinoma — periodic biopsy for any changing or non-resolving lesion is recommended

• Goldman-Cecil Medicine (International Edition), Chapters 392–393
• Cummings Otolaryngology: Head and Neck Surgery, Chapter 87

White Patch on the Lingual Gingiva Below the Incisors

Most Likely Diagnoses

• The lingual gingiva below the incisors is a site frequently traumatized by the tongue tip, food, or habits (e.g., tongue thrusting, rubbing)
• Produces a focal, well-demarcated white patch due to protective hyperkeratosis
• Typically does not rub off, asymptomatic, and resolves if the irritant is removed
• No malignant potential when clearly related to a mechanical cause

• A clinical diagnosis of exclusion — any white patch that cannot be attributed to another cause
• Can occur on the gingiva; appears as a smooth or wrinkled white plaque with sharp borders
• Does not rub off
• 2–6% risk of malignant transformation over time → biopsy is advisable for lesions that persist >2 weeks without an obvious cause
• Risk factors: tobacco use, alcohol

• Can affect the attached gingiva; plaque-form OLP may appear as a white patch in this area
• Look for associated white striae or bilateral lesions elsewhere in the mouth

• White plaques that can be wiped off, leaving a red/bleeding base
• If the patch in the image rubs off easily, candidiasis should be suspected

• A diffuse, filmy, whitish-grey opalescence of the mucosa
• Disappears or lessens when the mucosa is stretched — a key distinguishing feature
• Benign, no treatment needed

Key Clinical Question: Does it rub off?

Recommendation

• Persists for >2 weeks
• Cannot be attributed to a clear mechanical cause
• Is associated with tobacco use or is enlarging