A 54-year-old male patient presented with a chief complaint of burning sensation of the mandibular right gingiva and alveolar ridge on eating spicy food. The intensity of the burning sensation had increased over the previous 3 months. The patient has suffered from diabetes mellitus for 3 years and was on oral hypoglycemic agent metformin (500 mg/day). Intraoral examination revealed the presence of a raised, creamy white lesion on the mandibular right gingiva and alveolar ridge, with a ‘cottage cheese’ appearance (Figure 1, black arrows). The white lesion could be scraped, leaving an erythematous area that was painful. The patient was not receiving any antibiotics, corticosteroids, or other immunosuppressants. Primary testing with polymerase chain reaction showed a negative result for human immunodeficiency virus. The HbA1c test result was 7.2%, indicating that the diabetes mellitus was in an uncontrolled state. Smears from the scrapings of the lesion were strongly periodic acid–Schiff stain positive. To rule out precancerous and cancerous lesions, a biopsy was performed, which revealed hyperplastic epithelium, candidal hyphae penetrating the stratum spinosum, and chronic inflammatory cells in the lamina propria. On the basis of the clinical picture, laboratory tests, smear test, and biopsy, a final diagnosis of oral thrush (pseudomembranous candidiasis) was made. For systemic therapy, the patient was referred to an endocrinologist, who modified the dosage of oral hypoglycemic along with diet alterations, leading to an HbA1c level of 5.4%. For oral therapy, the patient was advised to use nystatin at doses of 100,000 IU/mL (5 mL, 4 times daily) and amphotericin-b 50 mg (5 mL, 3 times per day). Three-month recall of the patient revealed completely healed gingiva.
Oral thrush, also known as oral candidosis, oral candidiasis, moniliasis, oral mycosis, oral yeast infection, or candidal stomatitis, is a common opportunistic oral candida infection that develops in the presence of one of several predisposing conditions. Predisposing conditions include drugs, smoking, diabetes mellitus, malignancy, dentures, and immunosuppressive conditions.1 Candidal species are relatively common inhabitants of the oral cavity, gastrointestinal tract, and vagina of clinically normal persons. Oral thrush is caused by an overgrowth of the superficial fungus Candida albicans, which is a common inhabitant of the oral cavity, but, in the presence of predisposing factors, it has an ability to transform to a pathogenic hyphal form.2 Prevalence of oral candidiasis in diabetic patients is 13.7% to 64%.3 Oral thrush forms soft, friable, and creamy lesions on the mucosa that can be wiped off, leaving an erythematous painful surface. The buccal mucosa, palate, and tongue are common locations for oral thrush. Diagnosis of oral thrush is based on clinical features, smear examination, and biopsy. Management of oral thrush includes topical antifungal agents, removal of predisposing factors, and adequate oral hygiene.
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-Tanay Chaubal, MDS, Ranjeet Bapat, MDS
This article originally appeared in the September issue of The American Journal of Medicine.
