White and Red patches Flashcards
What to do with a white patch?
try to scrape off
- scrapes off = typical debris or thrush
- does not = thickened keratin → severe conditions
ask a thorough history
investigations = biopsy, blood test, immunofloresence
What is candida albicans in the oral cavity under normal conditions?
A harmless commensal organism
Under what circumstances can candida albicans become pathogenic?
When there is a disturbance of the oral flora or a decrease in immune defenses
What local factors should be ruled out first when diagnosing oral candida?
- denture-related issues (friction, not removing at night, denture stomatitis)
- smoking
- xerostomia
- antibiotics use
- topical steroids therapy (e.g. steroid inhalers)
What systemic factors can predispose a person to oral candidiasis
- uncontrolled diabetes
- haematinic deficiencies (iron, folate, B12)
- immunosuppression
- certain drugs
- endocrinopathies (e.g. diabetes, thyroid issues)
- HIV
What are the clinical variants of oral candidiasis?
- acute pseudomembranous candidiasis - commonly known as thrush
- acute atrophic candidiasis - associated with inahaler use
- chronic atrophic hyperplastic candidiasis: white pathces that cannot be wiped away, often extending to angular cheilitis. Seen in smokers, AIDS patients, and those with immunosuppression. Required fluconazole treatment.
- chronic erythematous candidiasis (median rhomboid glossitis): associated with a kissing lesion, often seen in smokers and inhaler users
what is chronic hyperplastic candidiasis, and why is it significant?
It is a form of candidiasis where white patches cannot be wiped away and has an increased potential for malignant transformation. It is often seen in smokers, AIDS patients, and those with immunosuppression
what is the treatment of choice for chronic hyperplastic candidiasis?
fluconazole
what is chronic mucocutaneous candidiasis associated with?
angular cheilitis, especially in cases with dentures that are too large or in elderly patients with reduced OVD (occlusal vertical dimension)
what deficiency is commonly associated with angular cheilitis
vitamin B12 deficiency
what are the characteristic features of acute pseudomembranous candidiasis in the oral cavity?
white papules with a milky appearance on the surface of the oral mucosa, which can be wiped off to leave a red, raw base
What are the local causes of acute pseudomembranous candidiasis?
- antibiotic use
- steroid use
- xerostomia
what are the systemic causes of acute pseudomembranous cadidiasis?
- systemic disease
- malignancy
- immunosuppression
what is the first step in treating acute pseudomembranous candidiasis
Remove any contributing factors, such as stopping or reducing use of antibiotics, steroids, or addressing xerostomia
what topical antifungals are used to treat acute pseudomembranous candidiasis
- nyastatin oral suspension (4 times a day)
- miconazole gel 2% (can be applied to denture fit surfaces or the corners of the mouth for denture stomatitis)
What are the systemic antifungals used for acute pseudomembranous candidiasis?
- fluconazole
- itraconazole
- voriconazole
Which antifungals used for treating acute pseudomembranous candidiasis can interact with warfarin and simvastatin, and what are the possible effects?
Miconazole and fluconazole can interact with warfarin and simvastatin, leading to very painful muscle cramps and wasting
What are the primary symptoms of acute atrophic candidiasis
a burning sensation in the mouth, which can be painful
What are the common causes of acute atrophic candidiasis
- use of asthma inhalers
- broad spectrum antibiotics
- deficiencies in B12, folate and ferritin
Where does chronic atrophic candidiasis (denture stomatitis) typically occur?
On the denture-bearing areas of the oral mucosa
Is chronic atrophic candidiasis (denture stomatitis) usually symptomatic or asymptomatic
It is typically asymptomatic
Which types of dentures are associated with chronic atrophic candidiasis
Both acrylic and Co-Cr dentures, especially chronic denture wearers.
What are Newton’s three types of chronic atrophic candidiasis (denture stomatitis)?
Type 1: Pinpoint (localized) erythematous areas
Type 2: Diffuse erythematous areas
Type 3: Erythema associated with granular or multinodular mucosa (indicative of chronic inflammatory papillary hyperplasia)
What are the clinical features of chronic hyperplastic candidiasis (candidal leukoplakia) ?
- Does not wipe off
- mainly occurs in smokers
often on buccal mucosa near the commisure - less common on the tongue
- higher risk of developing squamous cell carcinoma (6-8%)
What investigations should be performed for chronic hyperplastic candidiasis?
Swab - candida culture
FBC, haematinics, blood glucose
- histopathology after treating with antifungal agents to assess for dysplasia
How is chronic hyperplastic candidiasis treated?
- remove risk factors (eg smoking)
- use chlorhexidine 0.2% mouthwash, 100,000 units/ml, 1ml twice daily for 2 weeks
- Topical antifungals:
= Nystatin oral suspension: 100,000 units/ml, 1ml after food four times daily for 7 days, send 30ml
= miconazole oromucosal gel: 20mg/g, pea-sized amount after four times daily, send 80g tube - Systemic antifungals: Fluconazole, Itraconazole, Voriconazole
Why is fluconazole first-line treatment for chronic hyperplastic candidiasis?
A non-wipeable white patch indicated invasion into epithelial cells, so topical antifungals alone may not be effective. Fluconazole is first-line alongside smoking cessation and biopsy to assess for dysplasia if the lesion persists
What are they key features of white sponge naevus?
- needs to be referred - premalignant
- rare autosomal dominant disease - hereditary so must ask family history
- soft, white and spongy plaques in the oral muosa
- early childhood, adolescence
- benign course
How is white sponge naevus managed?
Treatment is challenging due to its genetic nature, but options include laser therapy or doxycycline
Where is smoker’s keratosis commonly found, and is it premalignant?
- Often found on the hard palate
- not considered premalignant
- associated with smoking or long-term drinking of hot beverages
What are the characteristic signs of smoker’s keratosis?
Pin-prick-like dots on the palate, caused by heat opening the ducts of minor salivary glands
What causes frictional keratosis and where is it commonly found?
- very common
- due to regular friction, mostly from teeth or dentures
- presents as linea alba in the cheks or buccal mucosa, often bilateral
- can be a discrete white patch anywhere in the mouth (esp edentulous ridges)
- should resolve if source or irritation removed
What is the management for frictional keratosis?
- Remove the frictional cause
- symptomatic relief if required
- biopsy if there is no improvement or if it is very dense to assess for dysplasia
What is leukoplakia and how is it disgnosed?
Leukoplakia is a clinical term for a white patch that cannot be removed and does not fit into other histological or morphologial diagnosis.
Clincial descriptor, not a diagnosis Diagnosis is made through histopathology to assess for dysplasia.
What are the malignant tranformation risk of leukoplakia?
4-6% risk
What are the clinical risk features of leukoplakia?
erythema, density, ulceration, locaation (lateral tongue, floor of mouth), sudden changes, spontaneous pain, hyperplastic margins (exophytic), verrucous keratosis / leukoplakia, pain and speckling
What is the management of leukoplakia?
Histopathological assessment for dysplasia, regular monitoring, re-biopsy if clinical changes occur, and avoid risk factors like tobacco and alcohol.
- if premalignant needs close monitoring
In which condition is hairy leukoplakia most commonly seen?
- most commonly seen in HIV infection
- may also be seen in other immunodeficient states like T-cell lymphoma and in patients taking ciclosporin
What are the clinical features of hairy leukoplakia?
- classically occurs on the lateral borders of the tongue with a corrugated surface, though it can also be smooth.
- Epstein-Barr virus is the likely cause, and it is not considered premalignant.
What is the prognostic significance of hairy leukoplakia in HIV patients?
80% of patients with hairy leukoplakia are likely to develop full-blown AIDS within 32 months
What viral infections are associated with oral lesions?
Hairy leukoplakia: Epstein-Barr Virus (EBV)
Warts and papillomas: Human Papillomavirus (HPV)
Koplik spots: Measles
Clinical Risk features of oral lesions?
- Speckling or heterogenous
- density,
- uleration
- location (lateral tongue, floor of mouth),
- sudden changes
- spontaenous pain/pain on palpatation,
- hyperplastic margins/exophytic
- verrucous keratosis/leukoplakiaappearance
What are the differential diagnoses for red patches in the oral cavity?
Atrophic or erosive forms of oral lichen planus
Candida infection
Vesiculo-bullous lesions
Erythroplakia or erythroleukoplakia (often associated with squamous cell carcinoma).
