Red Lesions
Erythematous (Atrophic) Candidiasis
aka Atrophic candidiasis · Antibiotic sore mouth (acute form)
A red, painful form of oral candidiasis presenting as diffuse or focal erythematous mucosal patches, often on the palate, dorsum of tongue or beneath dentures.
Red Flags
- ·Failure to respond to antifungals — biopsy for erythroplakia or lichen planus
- ·Recurrent episodes in previously healthy adult
- ·Weight loss, lymphadenopathy — evaluate for HIV
Clinical Tips
- ·Any painful red mucosa in a denture wearer — think Candida.
- ·Treat the denture and the patient together.
- ·If antifungals fail after 2 weeks — biopsy.
Examination Checklist
- ·Remove denture and examine underlying mucosa
- ·Assess denture fit and hygiene
- ·KOH mount
- ·Screen for HIV/diabetes if recurrent
§ overviewOverview
A form of oral candidosis in which mucosa appears red and atrophic due to loss of filiform papillae or thinned epithelium, secondary to Candida infection.
§ icdICD Classification
ICD-10 B37.0
§ etiologyEtiology
- 01Candida albicans (majority)
- 02Predisposing local (denture, xerostomia) or systemic (antibiotics, steroids, HIV, diabetes) factors
§ riskRisk Factors
- 01Broad-spectrum antibiotic use (acute erythematous form)
- 02Inhaled corticosteroids (palatal erythema)
- 03Denture wear (denture stomatitis)
- 04HIV / immunosuppression
- 05Diabetes mellitus
- 06Xerostomia
§ geneticsGenetics & Molecular Biology
- 01Same as generic candidiasis (CMC-related mutations in refractory cases)
§ epidemiologyEpidemiology
Common in denture wearers (30–60% incidence of denture stomatitis) and HIV patients. Acute antibiotic-induced form seen after broad-spectrum therapy.
§ pathogenesisPathogenesis
Candida hyphal invasion of epithelium causes inflammation, epithelial atrophy, loss of papillae, and vascular dilatation — appearing red rather than white due to lack of pseudomembrane.
§ clinicalClinical Features
- 01Diffuse erythema of palate under maxillary denture (denture stomatitis — Newton's II/III)
- 02Depapillated red patch on dorsum of tongue (central papillary atrophy → median rhomboid glossitis)
- 03Diffuse red painful mucosa after broad-spectrum antibiotics
- 04Kissing lesions: opposing palatal erythema mirrored on tongue
- 05Painful, burning sensation, sensitivity to acid/spice
§ signsSigns & Symptoms
- 01Burning tongue / palate
- 02Altered taste
- 03Pain on eating spicy or acidic food
- 04Denture soreness
§ differentialDifferential Diagnosis
- 01Erythroplakia
- 02Denture allergy (contact stomatitis)
- 03Vitamin B12 / iron deficiency glossitis
- 04Geographic tongue
- 05Anaemia
- 06Mucositis (radiotherapy/chemo)
- 07Lichen planus (atrophic)
§ criteriaDiagnostic Criteria
- 01Clinical + KOH mount / culture positive for Candida; response to antifungal therapy confirms
§ histopathHistopathology
- 01Epithelial atrophy with loss of rete ridges
- 02PAS-positive hyphae in parakeratin layer
- 03Chronic inflammatory infiltrate in lamina propria
- 04Absence of thick pseudomembrane (contrast with pseudomembranous form)
§ investigationsInvestigations
- 01KOH mount / oral rinse culture
- 02HbA1c, HIV screen, haematinics in recurrent cases
- 03Biopsy if not responding to antifungals
§ ihcIHC / Special Stains
- 01Not routinely needed
§ whoWHO Classification
Holmstrup–Axéll: acute erythematous (antibiotic sore mouth) and chronic erythematous (denture stomatitis, MRG) subtypes.
§ classificationClassification
- 01Acute erythematous — post-antibiotic
- 02Chronic erythematous — denture stomatitis, median rhomboid glossitis, HIV-associated linear gingival erythema
§ planTreatment Planning
- 01Identify and correct predisposing factor
- 02Topical antifungal for localised; systemic for extensive/refractory disease
- 03Denture hygiene reinforcement
§ treatmentTreatment
- 01Nystatin oral suspension 100,000 IU/ml QID × 14 days
- 02Miconazole oral gel or clotrimazole troches
- 03Fluconazole 100–200 mg/day systemically for refractory / immunocompromised
- 04Denture stomatitis: soak denture in chlorhexidine 0.2% overnight; replace ill-fitting dentures
- 05Reduce/change inhaled steroid; rinse mouth after use
§ medicalMedical Management
- 01Nystatin, miconazole (topical)
- 02Fluconazole (systemic)
- 03Chlorhexidine mouthwash adjunct
§ surgicalSurgical Management
- 01Not indicated
§ complicationsComplications
- 01Progression to chronic hyperplastic candidiasis
- 02Denture-bearing bone resorption in chronic denture stomatitis
- 03Recurrence
§ recurrenceRecurrence Rate
Very common (up to 70%) if predisposing factors persist.
§ followupFollow-up Protocol
- 01Review at 2 weeks; investigate systemic cause if recurrent
§ prognosisPrognosis
Excellent with treatment and control of predisposing factors.
§ preventionPrevention
- 01Denture hygiene, remove at night
- 02Rinse after inhaled steroid
- 03Glycaemic control
§ examKey Examination Points
- 01Denture-bearing mucosa
- 02Dorsum of tongue for depapillation
- 03Palate for kissing lesions
§ revisionQuick Revision Summary
- 01Red painful mucosa
- 02Antibiotic or denture history
- 03KOH positive for hyphae
- 04Topical nystatin + hygiene
- 05Investigate systemic disease if recurrent
§ vivaBDS Viva Questions
- 01Define erythematous candidiasis.
- 02Name subtypes.
- 03What is Newton's classification of denture stomatitis?
- 04How is it distinguished from erythroplakia?
- 05Role of denture hygiene.
- 06Systemic causes to investigate.
§ bdsBDS Professional Examination
- 01Short note: Denture stomatitis.
- 02Describe the aetiology, clinical features and management of erythematous candidiasis (10 marks).
§ fcpsFCPS Residency Questions
- 01Discuss the role of Candida species in oral potentially malignant disorders.
§ pearlsClinical Pearls
- 01Red + painful under denture = candidal denture stomatitis until proven otherwise.
- 02Treat patient AND denture — dentures are the reservoir.
§ mnemonicsMnemonics
- 01Red mouth after Rx (antibiotic) — think Candida
§ readingSuggested Reading
- 01Newton AV. Denture sore mouth. Br Dent J 1962.
- 02Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont 2011.
§ differentialDifferential Comparison
| Entity | Feature | Distinguisher |
|---|---|---|
| Erythroplakia | Red patch | Does not respond to antifungals; biopsy shows dysplasia |
| Denture allergy | Red palate under denture | Onset with new denture material; patch test positive |
| B12 deficiency glossitis | Red smooth tongue | Low B12, macrocytic anaemia |
§ mcqsMCQs — Assessment (5)
Question 1
Newton's Type II denture stomatitis is:
Question 2
Antibiotic sore mouth is a form of:
Question 3
Kissing lesion of the palate mirrors:
Question 4
First-line treatment is:
Question 5
Recurrent erythematous candidiasis in a young adult should prompt screening for:
References
- Neville BW. Oral & Maxillofacial Pathology, 4e
- Holmstrup P, Axéll T. Acta Odontol Scand 1990
Draft — pending faculty review. Educational use only; verify against current guidelines and primary sources before clinical application.