The Case of Central Papillary Atrophy

A 63-year-old male came to the dental school for some dental work. While performing the head and neck exam, absence of filiform papillae* was noted in the central region of the tongue. Once I pointed it out, the patient reported a burning sensation in the area.

Central papillary atrophy in a 63-year-old

This condition is described as central papillary atrophy and is the most common presentation of oral candidiasis. 

To prove that's what it is, I'm including the picture of the candida culture. The white opaque on the agar slope are the fungal colonies. 

Saboraud's agar exhibiting candida colonies.

This patient was a denture wearer so I recommended a course of anti fungal therapy with Clotrimazole troches, 50 tablets need to taken over a course of 10 days. The patient was also directed to soak his denture in a cup of a water containing 1 tablespoon of bleach (the one used for laundry). This kills the organisms hiding in denture porosities.

The presentation was previously referred to as median rhomboid glossitis and considered a developmental defect. Since this process is almost never seen in children but relatively common in adults, the possibility of it being a developmental defect is remote.

Please note that the mucosal-colored, dome-like structures behind the central papillary atrophy are normal anatomical structures called circumvallate papillae**.

Candidiasis:

Candida is a very common organism that is a part of normal oral flora in over 40% of the population. It is a weak organism and is only capable of producing surface alterations in healthy individuals. 

Changes associated with candida can be seen following antibiotic therapy. It is believed that antibiotic usage can alter the normal oral environment resulting in an overgrowth of candida. This increase produces the changes that we see in the mouth. 

Another group of people commonly afflicted with candidiasis are denture wearers. The porosities in acrylic (the pink material that forms the base of the denture) become a safe haven for the organisms. Although the number of organisms in the mouth may be within normal range, the organisms hidings in denture porosities can result in redness and in rare instances papillary hyperplasia. 

Loss of immune status can also result in candidiasis. Once the immune status is restored the infection should resolve on its own. In patients with HIV, oral candidiasis is a sign of extremely low CD-4 counts and onset of AIDS. Such patients should be placed on combined anti-retroviral therapy or CART (previously HAART) immediately. 

Oral candidiasis can present as either pseudomembranous, erythematous, denture stomatitis, chronic hyperplastic and mucocutaneous. Pseudomembranous candidiasis has a whitish, milk curd-like appearance. You can remove this white material with dry gauze or a tongue depressor to reveal normal colored mucosa underneath (underlying bleeding surface is a myth). 

Erythematous candidiasis is a lot common than people expect. Our case today is a type of erythematous candidiasis. This form of candidiasis may present with slight pain or burning sensation.

Angular cheilitis is redness and cracking at the corners of the lips. The lesions are usually seen in people that keep this area moist. People using a lot of oil-based lubricants for moisturizing and patients with dentures that pool saliva in this region.

Denture stomatitis has been described briefly when the etiology of oral candidiasis was being discussed. The organisms living within the denture result in redness or papillary hyperplasia at sites covered by the prosthesis.

Chronic hyperpastic candidiasis, also referred to as candidal leukoplakia are white lesions that cannot be scraped off by rubbing. Such lesions are almost indistinguishable from a regular leukoplakia in appearance. If you perform a culture, both may produce colonies due to the presence of commensal organisms or superinfection with candida. The only way to distinguish the two if to treat with antifungals. Lesions consistent with chronic hyper plastic candidiasis will resolve completely.

Mucocutaneous form of candidiasis is extremely rare and occurs in people with severe immunogenetic defect. One of the genes involved is called AIRE. With this particular defect, the endocrine system is also affected in this process. 

Appropriate anti fungal therapy (whether local or systemic) is recommended. If the patient wears denture, soaking in bleach solution can also be recommended. In case of frequent recurrences, the spouse may also need to be treated. 

*Filiform papillae are small, white projections that can be found on the anterior two-thirds of the mouth.

**Circumvalate papillae are slightly larger, dome-shaped structures that can be found anterior to the junction between oral and oropharyngeal portions of the tongue. They vary in number between 8 and 12 and arranged in the shape of an inverted "V". These structures are mucosal colored and often contain ducts of salivary glands and taste buds.