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Oral lichen Planus superimposed with candidiasis: A neglected, potentially dangerous combination
Pavan K Tupakula1, Ankita Kar2*, Ramya A Ganesh3, Rakesh Nagaraju4, Mahantesha S Chakrasali5, Ashwini S Gowda6,
Sujatha S Reddy7
1, 2, 4, 7
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Karnataka, India
3, 5, 6
Department of Periodontology and Implantology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Karnataka, India
Abstract
Lichen planus has been defined as a chronic systemic disease which commonly involves the oral mucosa. Lichen planus may present as
desquamative gingivitis (DG), clinically appearing as a red, tender, friable and glazed gingiva. Though relatively common, oral lichen
planus (OLP) has always been a matter of controversy, primarily in relation to its etiopathogenesis and possible potential for malignant
transformation. Histologically lichen planus has features of hyperkeratinisation which possibly has increased predisposition for candidal
infection. Often the erythematous areas in OLP manifests as the disease itself or a result of superimposed candidiasis, both of which are
concomitant with morbidity as soreness and pain. Hence, the objective of this paper is to report a case of OLP associated with candidal
infection and to discuss its potential for malignant transformation.
Introduction
“Desquamative gingivitis” was first described by Prinz in 1932 OLP (intrinsic risk factor). Here with we present a case,
which presents with areas of desquamation, erythematous and emphasising on the increased malignant potential of OLP due to
erosive regions, often with blistering of attached and marginal superimposed candidiasis.
gingiva [1]. The adult age group are usually affected. The
commonest cause of desquamative gingivitis is oral lichen planus Case Report
and also due to an abnormal response to bacterial plaque, aging, A female patient aged 55 years reported to the department of Oral
allergic reaction, chronic infections, autoimmune diseases or Medicine and Radiology with the chief complaint of itching and
idiopathic [2]. OLP is a chronic inflammatory oral mucosal burning sensation in her upper & lower gums since three months.
disease with an unknown aetiology. It is believed by most On eliciting the history, patient was apparently well 3 months
researchers that immunologic factors are involved. World Health back following which she developed burning sensation in her
Organization introduced OLP as a complication, which increases gums. It was associated with pain which aggravated on having
the potential for malignancy. Recently, investigators have spicy & hot food/ beverages and during daily oral hygiene
focused on the existence of pathogenic microorganisms, such as procedures. The symptoms persisted for 30 minutes and
Candida albicans in patients with refractory OLP and gradually subsided following the removal of the stimulant.
leukoplakia. Candidiasis is an infection cause by candida; mainly Patient had visited a dentist with the same complaint three
C. albicans which is seen in approximately 37% of OLP lesions months back where she was advised to apply:
[3]
. Candida albicans could become opportunistic pathogen when Rexidin- M gel BID x 15 days
the conditions of oral environment, i.e. decrease of oral immune Kenocort 0.1% BID x 15 days
response or the oral microorganism ecosystem change. OLP
symptoms may be exacerbated by candidal overgrowth or Following the application of the medication, there was mild
infection [4]. Numerous treatment modalities have been proposed decrease in the symptoms which backslid after 1 month. She
(each with pertinent side effect) even though disorders of immune visited the dental practitioner again, who performed oral
system are considered as common etiologic factors in OLP [3]. prophylaxis and changed her medication as follows:
Therapeutic management of OLP poses considerable problems to Mucopain gel BID x 8 days
the dental professional. Theoretically, in some cases of OLP, the Dentogel BID x 8 days
use of antifungal agents can diminish the potential of C. albicans
to produce carcinogen like N nitrosobenzylmethyl-amine [4, 3]. It Since patient did not have relief of symptoms, she was referred
is challenging to correlate whether there is a synergistic pre- to our hospital. On clinical examination: the patient presented
malignant effect in case of exposure to potentially carcinogenic with three different forms of lesions intraorally. Inspection of the
substances (contributing external risk factors) and persistence of lesions revealed erythematous, glazed, friable buccal and labial
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International Journal of Pathology Research
gingiva of maxillary and mandibular arch. Erosion of the surface prodrug 5-aminolevulinic acid (ALA) cream (5%, w/w). ALA
epithelium over the lesion was noted suggestive of desquamation cream was then applied evenly to the site. ALA-applied area was
of the gingiva (fig 1 A & B). On the maxillary attached gingiva covered with a black sheet for light protection. After 1 hour of
i.r.t. 21, 22, a diffuse whitish plaque was noted measuring application, excess ALA was removed from the lesions and light
approximately 1 x 1.5 cms in size at its greatest diameter. The irradiation was carried out using a 660nm diode laser. The
lesion had well defined boundaries. On palpation, it was treatment was repeated at two-week intervals, twice in a week
scrappable and non-tender. No bleeding from the site was noticed until complete remission was achieved. The assessment of
(Fig 1 B). Multiple irregular whitish striae noticed interlacing clinical improvement and adverse reactions was noted before and
each other surrounded by hyperpigmention on the right buccal after each treatment.
mucosa, measuring approximately 4 x 5cms in size at its greatest
diameter. Bilaterally in buccal mucosa, the lesion extended
anteriorly 1cm away from the commissure of the lip up to
retromolar trigome region posteriorly. The surrounding mucosa
appeared to be erythematous. On palpation, it was non-
scrappable and non-tender. No bleeding from the site was noticed
(fig 1 C & D). Based on the history and clinical examination a
provisional diagnosis of oral lichen planus superimposed with
pseudomembranous candidiasis was considered. Exfoliative
cytology was performed; the smears were taken from the
maxillary and mandibular labial mucosa, buccal mucosa (a) (b)
bilaterally and over the dorsum of the tongue. Patient was advised Fig 1: A & B Erosion of the surface epithelium over the lesion was
routine haematological investigation and since the patient did not noted suggestive of desquamation of the gingiva
present with any clear immune-compromised state (for candidal
infection); she was advised for a HIV test. Following this, patient
underwent supra-gingival scaling. A topical anaesthetic (annabel
gel) was prescribed which in turn caused hypersensitivity
reactions. Therefore she was advised to discontinue Annabel gel
and was replaced with normal saline mouth wash as alcohol base
mouthwash would worsen her symptoms. All her haematologic
investigatory reports were normal. Cytology impression revealed
class I cytological smear with inflammation and positive for
candida. CANDID-B (clotrimazole + beclomethasone) powder (c) (d)
was added to her prescription and patient was instructed to use
the powder by applying in the occlusal splint/ medication tray Fig 1: C & D multiple irregular whitish striae noticed interlacing each
other surrounded by hyperpigmention on the right buccal mucosa and
thrice daily for an hour for 2 weeks (Fig 2). On follow up, there
left buccal mucosa
was marked decrease in both signs and symptoms and no fresh
complaints were observed (Fig 3 A, B, C & D). Incisional biopsy
was performed and histopathological characteristics revealed a
fragment of oral mucosa lined by stratified squamous epithelium,
with areas of para or orthokeratosis, spongiosis, acanthosis, focus
of hydropic degeneration and degeneration of the basement layer.
Fibrous connective tissue with variable density was seen in the
underlying lamina propria which also presented with an intense
inflammatory infiltrate, mainly lymphocytic, situated in the
subepithelial region and arranged in a band-like pattern.
Dysplastic alterations were also noted in the basilar and
parabasilar portions of the epithelium indicative of mild to
moderate dysplasia. Patient was advised application of TESS
ointment (triamcinolone acetonide 0.1%) twice daily for 15 days
and recalled after a month. The symptoms had subsided but there
was no complete remission of the disease. A Visual Analog Score
(VAS) for each site was noted to assess pain and burning
sensation individually. Therefore Photodynamic therapy (PDT)
was advised for the patient since it has been proven to be effective
in the treatment of premalignant and malignant cutaneous lesions.
The lesions were first cleaned with normal saline solution
followed by topical administration of PDT mediated with Fig 2: Occlusal splint
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International Journal of Pathology Research
(a) (b)
(c) (d)
Fig 3: A, B, C & D Marked decrease in erythematous areas and healing of signs of lichen planus noted on the right and left
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International Journal of Pathology Research
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