Medically reviewed by Candida leukoplakia or hyperplastic candidiasis is a rare but important variety of Candida albicans oral disease that develops due to over proliferation of Candida albicans. This is a chronic form of oral thrush unlike other forms of this disease and may be incurable to regular antifungal treatments. It manifests as white plaques on the oral mucosa which are not easily wiped off, this is the major characteristic that differentiates it with other fungal infections of the mouth. Hyperplastic candidiasis is not very prevalent as compared to pseudomembranous or erythematous candidiasis and therefore should not be ignored because it is potentially premalignant, i.e., it can lead to oral cancer when not treated.
Hyperplastic candidiasis is manifested by persistent white patches that usually occur on the buccal mucosa and tongue or commissures of lips. These patches tend to be very adherent, that is, they could not be scraped off as in the case of pseudomembranous candidiasis.
This is the most common condition observed amongst middle aged or old men particularly those who smoke or wear dentures. Candida fungus, which as a rule does not cause any harm to the organism, acquires the properties of a pathogen in favorable conditions that include poor oral health, smoking, or an impaired immune system.
Epidemiology of Hyperplastic Candidiasis
Less than 5 percent of all cases of oral candidiasis involves hyperplastic candidiasis. It is more common among immunocompromised people including those who have HIV/AIDS, diabetes mellitus, or cancer therapy.
Prevalence by Gender
| Gender | Estimated Occurrence |
|---|---|
| Men | 60–70% of reported cases |
| Women | 30–40% of reported cases |
Inequality in terms of dental care, nutritional deprivation, and access to antifungal drugs are some of the factors that predispose people in developing countries to higher levels of oral fungal infections such as hyperplastic candidiasis.
Infection with Candida albicans is the primary reason of hyperplastic candidiasis, but other species of Candida, including Candida tropicalis and Candida glabrata, could also be implicated.
Major Risk Factors
Smoking: Candida is sensitive to tobacco smoke, which alters the oral mucosa, thereby providing it with a favourable environment to grow.
Oral Hygiene: Debris accumulation and plaque promote the growth of fungi.
Immunosuppression: Diseases (such as HIV or cancer), or chronic corticosteroid use, make one susceptible.
Dentures and Oral Appliances: Poorly cleaned dentures serve as fungi reservoirs.
Diabetes Mellitus: This increases glucose in saliva and this promotes fungi.
Use of antibiotics: When used long-term, it interferes with the normal microbial balance, which enables the growth of Candida.
The hyperplastic candidiasis pathogenesis is the transformation of Candida albicans into an innocuous commensal organism into an invading pathogen. Candida can change its form under favorable conditions (e.g. under immunosuppression, mucosal injury smoking; etc) to a hypha form, which invades the epithelial tissue and leads to the inflammation.
The result of this chronic irritation and inflammation is the epithelial hyperplasia or excessive thickening of the mucosal layer- resulting in persistent white plaques. With time there may be dysplastic changes (pre-cancerous changes) in the affected tissues.
Clinical Features
| Clinical Feature | Description |
|---|---|
| Appearance | White, raised plaques or patches that cannot be wiped off |
| Location | Commonly found on the buccal mucosa (inner cheeks) and lateral borders of tongue |
| Surface Texture | Thickened, rough, or nodular surface |
| Symptoms (Early Stage) | Usually asymptomatic |
| Symptoms (Advanced Stage) | Burning sensation or discomfort, especially with spicy or acidic foods |
| Inflammation | May show surrounding erythema (redness) indicating irritation or inflammation |
Diagnosis of Hyperplastic Candidiasis
The diagnosis of hyperplastic candidiasis involves a combination of clinical evaluation and laboratory investigations to confirm the presence of Candida and rule out other oral lesions.
Clinical Examination
A dentist or oral specialist identifies characteristic white, adherent plaques that do not rub off during examination. These lesions are typically located on the buccal mucosa or tongue.
Smear or Cytological Test
An oral smear is obtained, and the sample is stained using Periodic Acid–Schiff (PAS) or Gram stain to detect Candida hyphae or pseudohyphae, confirming fungal involvement.
Fungal Culture
To identify the specific Candida species, a sample is cultured on Sabouraud Dextrose Agar (SDA) or other selective fungal media. This helps determine species and potential antifungal resistance.
Biopsy
In chronic, non-responsive, or atypical cases, a tissue biopsy is recommended. Histopathological examination assesses for epithelial dysplasia or early malignant transformation, as hyperplastic candidiasis carries a small risk of progression to oral cancer.
Treatment and Management
Effective management of hyperplastic candidiasis involves antifungal therapy, elimination of contributing risk factors, and regular follow-up due to its potential for malignant transformation.
Antifungal Medications
Topical Antifungals (First-line for mild to moderate cases):
- Nystatin oral suspension – Used as a mouth rinse several times daily to reduce fungal load on the mucosa.
- Clotrimazole troches/lozenges – Slowly dissolved in the mouth to maintain prolonged contact with affected areas.
Systemic Antifungals (For severe, widespread, or treatment-resistant cases):
- Fluconazole – Commonly prescribed oral antifungal with good tissue penetration.
- Itraconazole – Used when fluconazole resistance or treatment failure is suspected.
Important Note on Antifungal Therapy:
Patients should complete the full duration of antifungal treatment even if symptoms improve early. In cases of recurrent infection, fungal culture and susceptibility testing may be required to identify resistant strains of Candida.
Elimination of Predisposing Factors
Addressing underlying risk factors is essential to prevent recurrence:
Smoking cessation programs: Smoking irritates the oral mucosa and promotes fungal growth; quitting improves treatment outcomes.
Improved oral hygiene: Regular brushing, flossing, and tongue cleaning help reduce microbial load and maintain oral health.
Denture care: Dentures should be cleaned, disinfected, and polished regularly to prevent fungal colonization.
Management of systemic conditions: Conditions such as diabetes and immunosuppression must be controlled to reduce susceptibility to infection.
Limiting prolonged antibiotic or corticosteroid use: Whenever possible, avoid unnecessary long-term use, as these medications can disrupt normal oral flora and promote Candida overgrowth.
Long-Term Monitoring
Hyperplastic candidiasis is considered a potentially premalignant condition. Therefore:
- Regular follow-up every 6 months is recommended to monitor lesions.
- Persistent or non-resolving lesions may require repeat biopsy to detect epithelial dysplasia or early malignant transformation.
- Patient education is essential to ensure ongoing oral self-examination and prompt reporting of changes such as ulceration, hardness, or increased thickness.
Complications
Late untreated hyperplastic candidiasis may result in:
- Persistent oral discomfort
- Secondary bacterial infections
- Dysplasia or malignancy of epithelial cells
- Chronic mucosal irritation
Conclusion
Hyperplastic candidiasis is an oral fungus, which is chronic and may be pre-malignant and needs to be diagnosed and treated with maximum attention. The main goals of preventing complications are awareness, early detection, and lifestyle change. Regular oral hygiene and professional dental care will allow people to manage this condition and prevent the disease.
FAQs
1. What is hyperplastic candidiasis?
Candidal leukoplakia or hyperplastic candidiasis is a long-lasting fungal infection of the mouth, caused by Candida albicans. It is witnessed as white thickened plaques which are not scrapable and can have a risk of malignant transformation.
2. Is candidiasis hyperplasia contagious?
No, it is not directly contagious. Although Candida organisms may be transmitted, the disease is only developed in favorable conditions such as immunosuppression, poor oral hygiene or smoking.
3. What is the difference between hyperplastic candidiasis and oral thrush?
Belonging to oral thrush (pseudomembranous candidiasis), the white patches may be wiped off whereas hyperplastic candidiasis causes solid white lesions that are not scrapable.
4. Is hyperplastic candidiasis cancer causing?
Hyperplastic candidiasis may malignantly transform into oral squamous cell carcinoma in a few long-term cases, particularly in smokers. Therefore, it is important to have frequent monitoring.
5. What is the optimal therapy of hyperplastic candidiasis?
Topical or systemic antifungal agents, such as Nystatin or Fluconazole, and changes in lifestyle including cessation of smoking and oral care are all considered treatment.