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Pathology · patient case with 3 questions

Asthmatic man with white plaques on the tongue and buccal mucosa

Patient: Male, 41 years old

Chief complaint: “I'm here for a check up and I want a cleaning done today.”

Background: Asthma. Medication: beclomethasone dipropionate (Qvar®) inhaler.

Current findings: White plaques on the buccal mucosa and dorsal surface of the tongue. The plaques wipe away, leaving erythematous mucosa underneath.

Question 1

What is the diagnosis?

  1. Leukoplakia
  2. Oral hairy leukoplakia
  3. Oral lichen planus
  4. Pseudomembranous candidiasis
Show answer and explanation

Correct answer: D. Pseudomembranous candidiasis

  • A. Leukoplakia is by definition a white patch that does not rub off and cannot be attributed to another cause.
  • B. Oral hairy leukoplakia occurs on the LATERAL tongue in immunosuppression, is EBV-driven, and does not rub off.
  • C. Lichen planus produces fine white striae (Wickham striae) that CANNOT be rubbed off, usually bilaterally on the buccal mucosa.
  • D. CORRECT. A WIPEABLE white plaque leaving an erythematous base is the defining feature of PSEUDOMEMBRANOUS CANDIDIASIS (thrush). The inhaled corticosteroid provides the local immunosuppression that permits candidal overgrowth.

Note: The single discriminating question for any white lesion: does it wipe off? If yes, think candidiasis.

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Question 2

Which is the most appropriate recommendation?

  1. Switch the prescription to a different inhaler
  2. Stop using the inhaler
  3. Obtain an antifungal prescription from his physician
  4. Rinse with water after each use of the inhaler
Show answer and explanation

Correct answer: D. Rinse with water after each use of the inhaler

  • A. Changing an asthma prescription is the physician's decision, and is unnecessary for a preventable local side effect.
  • B. Never advise a patient to stop a controller asthma medication. That is dangerous and outside your scope.
  • C. Antifungal therapy may be warranted for an active symptomatic infection, but the BEST recommendation targets the cause. Note also that you would prescribe it yourself, not send him to his physician for it.
  • D. CORRECT. This addresses the CAUSE and prevents recurrence. Residual corticosteroid deposited on the mucosa is what permits candidal overgrowth; rinsing and spitting after each use, and using a spacer, removes it. This is squarely within the dentist's scope and is the best answer.

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Question 3

Which organism is responsible?

  1. Candida albicans
  2. Staphylococcus aureus
  3. Streptococcus mutans
  4. Epstein–Barr virus
Show answer and explanation

Correct answer: A. Candida albicans

  • A. CORRECT. Candida albicans is a commensal yeast that becomes pathogenic when local or systemic immunity is impaired — here by topical corticosteroid deposition.
  • B. S. aureus is implicated in angular cheilitis alongside Candida, but not in pseudomembranous plaques.
  • C. S. mutans is the principal cariogenic organism, unrelated to this lesion.
  • D. EBV causes oral hairy leukoplakia and infectious mononucleosis.

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