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Candidal Leukoplakia
(Chronic Hyperplastic Candidosis /
Candidal Epithelial Hyperplasia)
Chronic Hyperplastic Candidiasis or Candidal
Leukoplakia
is a persistent white lesion, characterised
keratin  (parakeratosis) and chronic intra-epithelial
inflammation
with fungal (Thrush) hyphæ invading the
superficial layers of the
epithelium (top-most layer of
the skin).
Photo of Candidal Leukoplakia (of the R Commissure)
B&W Photo of Candidal Leukoplakia (of the R Commissure)
What is Candidal Leukoplakia?

Chronic oral candidosis produces a tough, adherent, white
plaque (
leukoplakia), distinguishable only by biopsy from
other
leukoplakias.

Chronic hyperplastic candidiasis or candidal leukoplakia
is a persistent white lesion, characterised
histologically
(under the microscope) by
parakeratosis (increased
keratin production) and
chronic intra-epithelial (within skin
cells)
inflammation with fungal hyphæ (shape of fungus)
invading the superficial layers of the
epithelium (skin).

Candidal leukoplakia is an uncommon condition found in
adults.
background ('speckled').  Angular stomatitis may be associated, is sometimes
continuous with
intra-suggests the candidal nature of the lesion.

Candidal leukoplakias are chronic, discrete, raised lesions that vary from small,
palpable, translucent, whitish areas to large, dense, opaque plaques, hard and
rough to the touch (plaque-like lesions).  
Homogeneous areas or speckled areas
can be seen, which do not rub off (
nodular lesions).

Candidal leukoplakias are non-homogeneousspeckled' leukoplakias in up to
50%.

Candidal leukoplakias usually occur on the buccal mucosa on one or both sides,
mainly just inside the
commissure, less often on the tongue.


How Is It Diagnosed?

Unlike Thrush, the plaque cannot be wiped off but fragments can be detached by
firm scraping.  Under the microscope,
Candidal hyphæ are seen in amongst the
epithelial cells.  The hyphæ are seen growing (as in Thrush) through the full
thickness of the
keratin to the prickle cell layer of the skin, where the inflammatory
cells tend to be more concentrated.

Electron microscopy shows
Candida albicans to be an intra-cellular parasite
growing within the
epithelial cytoplasm.

Induction of epithelial proliferation by C. albicans infection has been demonstrated
experimentally.  
Dysplasia may be present, especially in speckled lesions.

Candidal leukoplakia should be biopsied both to:

  • distinguish it from other non-candidal lesions
  • examine for possible dysplasia.


How is it treated?

After confirmation of the diagnosis by histology, treatment should be with a
systemic anti-fungal drug such as
fluconazole (this may have to be continued for
several months).  Other factors likely to perpetuate
candidal infection should be
controlled.

Stopping the patient from smoking and elimination of
candidal infection from under
an upper denture are important.  Any iron deficiency should also be treated.

Excision of
candidal plaque alone is of little value, as the infection can recur in the
same site even after skin grafting.  Vigorous anti-fungal therapy is therefore
essential but sometimes some residual (uninfected) plaque may persist after
treatment and lesions often recur and require long-term intermittent anti-fungal
therapy.


Prognosis

The potential for malignant change exists.  The level of risk is controversial but
low (9% to 40% of
candidal leukoplakias may develop into carcinomas [cancers]).

Factors influencing the prognosis may include:

  • risk factors, such as tobacco and alcohol use
  • whether the lesion is speckled (more dangerous) or homogeneous
  • the presence (more dangerous) and degree of epithelial dysplasia

In order to improve the prognosis:

  • Tobacco and alcohol habits should be stopped.
  • Anti-fungals should be used.  The lesions of candidal leukoplakia may prove
    poorly responsive to polyene anti-fungal drugs and, in some cases, respond
    only to systemic fluconazole.
  • Excision is indicated if there is more than mild dysplasia.
  • The patient should be fully informed about the condition and reviewed regularly.



Useful Websites:

Critical Reviews in Oral Biology & Medicine

Oral Cancer LDV


Useful Articles:

Postgrad Med J 2002.  Oral Candidiasis.

Critical Reviews In Oral Biology & Medicine 2003.  Chronic Hyperplastic
Candidosis-Candidiasis (Candidal Leukoplakia)
Last Updated 10th April 2015
What is the Cause of Candidal Leukoplakia?

The epithelium of some leukoplakias is invaded by Candida hyphæ but it is unclear
whether the yeasts are secondary invaders or are causally involved in the
development / transformation of
leukoplakia.

  • The cellular changes often include hyperplasia; however, cellular changes can
    occur that range from mild dysplasia to invasive carcinoma.
  • C. albicans is the species of fungus that is most commonly found in
    association with candidal leukoplakia.
  • The Candida biotypes associated with candidal mouths.

Candidal leukoplakia may be predisposed to in a minority of patients by:

  • smoking
  • iron and folate deficiencies
  • defective cell-mediated immunity
  • blood group secretor status.


What are the signs and symptoms?

Adults, typically males of middle age or over, are affected.