Introduction

Candida is one of the most common microorganisms isolated from oral cavity in 30% of healthy individuals. ⁽¹⁾ The most common form of candidiasis noted in practice by General Dentists is pseudomembranous candidiasis. This clinical scenario of medically compromised patient with other systemic conditions and presenting clinical lesions in oral cavity makes this case unique for discussion for general dentistry practitioners. Unlike pseudomembranous candidiasis which can be wiped with gauze, atypical presentation of candidiasis in hyperplastic form challenges a clinician to include it as a differential diagnosis. This variety of candidiasis is termed as chronic hyperplastic candidiasis and it has a characteristic hyperkeratotic plaque appearance resembling oral leukoplakia that cannot be wiped, and is usually asymptomatic seen on buccal mucosa and lateral border of tongue. ⁽²⁾ Due to its atypical appearance it is also named as candidal leukoplakia. It is known to be most commonly associated with smoking and smoking cessation could result in complete resolution. ⁽³⁾ Lesions could vary from small to large well circumscribed elevated white plaques and either have a nodular or speckled appearance. ^(4-9) According to some studies, this form of candidiasis is also known to progress to severe dysplasia and malignancy when compared to non-candidal leukoplakia. ⁽¹⁰⁾ However, other published articles expressed controversy on such malignant potential of these lesions. ⁽²⁾ Other oral conditions that have a similar appearance and to be included in differential diagnosis are leukoplakia, lichenplanus, pemphigoid/pemphigus and squamous cell carcinoma. ⁽¹¹⁾

Patient information

A 54-year-old female patient presented to our dental clinic for a problem focused exam with primary concern of white patches/ lesions in her mouth for last one week. Per patient’s history she was initially seen by her primary care physician for the same concern and was recommended to see a Dentist or an ENT specialist for further evaluation and management. During the consult and discussing patient’s medical history, patient disclosed that she has a medical history of severe eczema for which she is on multiple medications. Her medical records did not pull up any specific medications for eczema and the patient could not recollect names and dosage of her current medications. She stated that she takes Benadryl for symptomatic relief and to relieve itching from eczema.  In regards to her history of presenting illness, the patient stated she had similar lesions a month ago which subside and flare up occasionally. Patient was seen by her primary care physician and was referred to a general dentist and an ENT specialist simultaneously. Patient did not give any symptoms of burning or pain in the history of presenting illness nor had any concerns during palpation. Patient’s unclear medical history and pharmacological management of other systemic conditions with atypical presenting lesions lead to challenges in the differential diagnosis and management.

Clinical findings

Clinical intraoral exam revealed multiple white eruptions disseminated over entire oral mucosa including all the soft tissue on buccal mucosa (Figure 1, 2, 3), tongue (Figure 4) floor of the mouth (Figure 5) and palate (hard and soft palate (Figure 6) with exception of gingiva. However, patient's history stated that occasionally such lesions were noticed on gingiva in the past. Lesions measured approximately 2-4mm in circumference. The lesions could not be wiped away with gauze, were not associated with pain and had a hard keratotic feel on palpation. No purulent, serous or mucus discharge was noted from the lesions. Presenting lesions had a combination of different varieties as mentioned in the presented clinical photographs. No other physical exam findings of lymph node involvement or signs of any systemic infection were recorded.
 

Figure 1: Lesions on buccal mucosa Click here to view Figure

Figure 2: Lesions on buccal mucosa with white plaque appearance. Click here to view Figure

Figure 3: Lesions on buccal mucosa with lace like pattern Click here to view Figure

Figure 4: Plaque like lesions on lateral border of tongue extending on to the ventral surface. Click here to View Figure

Figure 5: Lesions on floor of the mouth with nodular appearance. Click here to view Figure

Figure 6: Multiple palatal non-wipeable white lesions with surrounding erythema that are hard in texture to palpation. Click here to view Figure

Table 1: below is a brief description of presenting symptoms during patient’s appointments.
 

Due to lack of diagnostic procedures at our facility, no diagnostic tools were used to arrive at a final diagnosis. This significantly contributed to the existing diagnostic challenges of unclear medical information from patient's history. Due to patient’s complex medical history and multiple unclear medications that patient is undergoing treatment for other systemic conditions, it was challenging to arrive at a final diagnosis without further tests. Few of the differential diagnosis that were considered included Hyperplastic candidiasis, Oral manifestations of eczema, leukoplakia, lichenplanus and oral pemphigoid/pemphigus. Due to lack of a final diagnosis, prognosis of treatment or resolving the clinical scenario remained unpredictable during the initial visit. However, as discussed below, a successful outcome of antifungal treatment that lead to almost complete resolution of lesions changed the prognosis of the presenting condition from unpredictable to excellent.

Therapeutic intervention, Follow up and outcomes

Due to lack of a final diagnosis, no therapeutic intervention was initiated in our practice. At a 3 week follow up appointment, as per patient's history, due to recent flare up of eczema, her primary care physician prescribed a very high bolus dose of steroid medications. Patient forgot to disclose this critical information during her initial visit in our practice. However, she disclosed this information during her visit to the ENT specialist and she was treated for yeast infection / thrush and that helped the lesions heal up. The ENT specialist made a professional decision to treat for hyperplastic candidiasis. Patient completed an entire course of Clotrimazole course prescribed by her ENT specialist. Patient brought in her prescription details of Clotrimazole. According to those records, ENT specialist prescribed Clotrimazole 10mg troche 5 times a day for 2 weeks. During the follow up visit, patient’s lesions healed up almost up to 98% with two small remnant lesions noted on the hard palate. Due to exceptional response of lesions to antifungal medications, a final diagnosis of hyperplastic candidiasis was derived.

Discussion

Limitation in this case report includes lack of diagnostic tests at our facility to attain a final diagnosis due to which the patient had to be referred out to an ENT specialist. Patient's unclear or partial disclosure of medical information in regards to her treatment for eczema posed a critical challenge in diagnosis, evaluation and management. When unsure and in a clinical dilemma with no access to further diagnostic tools, an unclear medical history and a challenging clinical lesion, referring to an ENT specialist can be considered as a strength in this case scenario. Though referral to an oral pathologist or an oral medicine department would be ideal, due to lack of such services in this specific geographical area, patient’s insurance and financial concerns dictated the patient to follow up with an ENT specialist. Though patient could not be treated at our facility, an arrangement of follow up with a concerned professional lead to patient's satisfactory experience and a successful outcome. Future collaborations with oral pathology department at UTHSC college of Dentistry through Tele Dentistry are being considered for handling similar patient scenarios.

Below is a brief discussion on variation in clinical presentation, contributing factors, diagnostic tests and pharmacological management for application in clinical dentistry

Table 2 discusses classification and clinical variation in presentation

Table 2: Classification and terminology.

Table 3 discusses local and systemic risk factors that contribute to develop candidiasis

Table 3: Contributing risk factors.

Diagnostic tests

10% KOH - Digests pseudo membrane and reveals spores, yeast forms and mycelia. ⁽¹⁶⁾

PAS - Periodic Acid Schiff stain - A smear from infected area is fixed in alcohol and stained with PAS reveals fungal organisms under a microscope. ^(15,16)

Saboraud Agar plates - These can be used for culture to identify the causative organism and its species in cases where initial antifungal medications were not successful in treatment, immunocompromised patients and recurrence scenarios. ⁽¹⁵⁾

Biopsy with fungal stain - This method can be used in clinical cases where chronic hyperplastic candidiasis did not respond to antifungal treatments and to rule out possible dysplasia or malignancy. ⁽¹⁵⁾ Table 4 below discusses medical management available for treatment.

Table 4: Treatment:*

* Adapted and modified from ^{(4, 26)}

Conclusion

Primary take away from this case report is to have a thorough knowledge of variation in presentation of oral candidiasis, differential diagnosis to be considered in atypical presenting lesions and ideal management or referral when clinically not possible to diagnose and manage in a general dentistry setting.

Acknowledgements

Thank you Ms. Mary Grace Hilario and Ms. Tonja Messer for helping with clinical photography.

Conflict of interest

The author(s) declare no conflict of interest. 

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