Oral candidiasis

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ORAL CANDIDIASIS

HEMAM SHANKAR SINGHFINAL YEAR BDS

ROLL NO. 16

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CONTENTS1. INTRODUCTION2. CLASSIFICATION3. ACUTE PSEUDOMEMBRANOUS CANDIDIASIS (THRUSH)4. ACUTE ATROPHIC CANDIDIASIS5. CHRONIC ATROPHIC CANDIDIASIS6. CHRONIC HYPERPLASTIC CANDIDIASIS7. CHRONIC MULTIFOCAL CANDIDIASIS8. CHRONIC MUCOCUTANEOUS CANDIDIASIS9. IMMUNOCOMPROMISED (HIV)-ASSOCIATED CANDIDIASIS10. TREATMENT OF ORAL CANDIDIASIS

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INTRODUCTION

“Candidiasis” refers to a multiplicity of diseases caused by a yeast like fungus, Candida, and is the most common oral fungal infection in humans.

It is also called as candidiosis.

Older name of candidiasis is “moniliasis”.

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CLASSIFICATIONThe various diseases are classified in according to 1. onset and duration (acute or chronic)2. clinical features, including color (erythematous/atrophic) 3. location (median rhomboid glossitis, denture stomatitis,

multifocal candidiasis, and angular cheilitis)4. the presence of skin lesions as well as oral lesions

(mucocutaneous) and 5. Association with an immunocompromised host (HIV

associated).

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CLASSIFICATION OF ORAL CANDIDIASIS.Acute

i. Pseudomembranousii. Atrophic (erythematous)

a) Antibiotic stomatitis

Chronici. Atrophic

a) Denture sore mouthb) Angular cheilitisc) Median rhomboid glossitis

ii. Hypertrophic/hyperplastica) Candidal leukoplakiab) Papillary hyperplasia of the palatec) Median rhomboid glossitis (nodular)

iii. Multifocal

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CLASSIFICATION OF ORAL CANDIDIASIS. Mucocutaneous

i. Syndrome associateda) Familial +/– endocrine candidiasis syndromeb) Myositis (thymoma associated)

ii. Localizediii. Generalized (diffuse)

Immunocompromise (HIV) associated

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. Conditions associated with increased vulnerability of oral candidiasis and their mechanism

Category Condition MechanismAltered local resistance to infection

Poor oral hygiene Promotes organism adherence & colonization

Xerostomia Absence of antimicrobial & flushing effect of saliva

Recent antibiotics treatment Inhibits competitive oral bacteria

Dental appliance Isolate mucosa from saliva & functional cleansing serve as organism reservoir

Compromised immune system Early infancy Immune competence has not completely developed

Genetic immune deficiency Specific humoral or cellular immune defects

AIDS Deficient cellular immune response

Corticcasteroids therapy Inhibition of immune functionPancytopenia Depletion of circulating leukocytes caused by chemotherapy, aplastic

anaemia & similar hemopoietic disorders

Generalized patient debilitation

Anemia, malnutrition, malabsorption Epithelial thinning & altered maturation, poor tissue oxygenation

Diabetes mellitus Recurring hyperglycemia & mild ketoacidosis

Advanced systemic disease Metabolic toxicity or limited blood perfusion of tissues

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ACUTE PSEUDOMEMBRANOUS CANDIDIASIS (THRUSH)

Clinical Features. Thrush is the prototype of the oral infections caused by

Candida. Superficial infection of the outer layers of the epithelium, Patchy white plaques or flecks on the mucosal surface Removal of the plaques by gentle rubbing or scraping usually

reveals an area of erythema or even shallow ulceration. Seen in children and in adults of all ages common in women

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A, Patchy white plaque and flecks that rubbed off represent thrush. The patient complained of a burning mouth. B, More-extensive pseudomembranous lesions associated with an erythematous base in an adult with severe thrush

A B

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• Typical lesions in infants are – as soft white adherent patches on the oral mucosa – generally painless, – can be removed with little difficulty, leaving raw bleeding

surface– infection is contracted mother during pregnancy

In adult, inflammation, erythema, and painful eroded areas

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• INFANT THRUSH

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Any mucosal surface may be involved, erythematous or white areas often develop beneath partial or

complete dentures (areas where normal cleansing mechanisms are poor)

A prodromal symptom of a rapid onset of a bad taste and the loss of taste discrimination burning sensation of the mouth and throat may also

precede

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• pearly white or bluish white plaques are present on the oral mucosa, they resemble cottage cheese or curdled milk

• white patches are easily wiped out with wet gauge which leaves either a normal or erythematous area or atrophic area

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Micro-organisms associated• Candida albicans, • Candida tropicalis, and• Candida glabrata account for over 80% of medical isolates;• Candida parapsilopsis,• Candida guilliermondii,• Candida krusei, and • Candida pseudotropicalis are also recognized as pathogens.

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Predisposing Factors1. Marked changes in oral microbial flora

1. due to the use of antibiotics [especially broad-spectrum antibiotics],2. excessive use of antibacterial mouth rinses, or xerostomia

2. Chronic local irritants (dentures and orthodontic appliances)3. Administration of corticosteroids (aerosolized inhalant and

topical agents are more likely to cause Candidiasis than systemic administration)

4. Poor oral hygiene

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5. Pregnancy6. Immunologic deficiency

1. congenital or childhood (chronic familial mucocutaneous candidiasis ± endocrine candidiasis syndrome [hypoparathyroidism, hypoadrenocorticism], and immunologic immaturity of infancy)

2. acquired or adult (diabetes, leukemia, lymphomas, and AIDS)3. iatrogenic (from cancer chemotherapy, bone marrow transplantation,

and head and neck radiation)

7. Mal-absorption and malnutrition

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• Xerostomia and chronic local irritants may alter the oral mucous membranes, predispose them to colonization and invasion

• Shifts in the bacterial flora often accompany these situations and provide an opportunity for Candida spp to increase.

• Radiation to the head and neck also affects the oral mucous membranes and produces xerostomia

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Histologic Features. Microscopic examination of the lesions reveals a

localized superficial inflammatory reaction,hyperparakeratosis and ulceration of the surface covered with a fibrinoid exudate, In fibrinoid exudate large numbers of yeast and

pseudohyphae are found .

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Histologic Features. The fungi rarely penetrate below this superficial layer.

This pseudo-membrane imparts the characteristic white-flecked appearance to the mucosal lesions. Thrush is correctly described as an acute pseudo-membranous candidiasis.

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DIFFERENTIAL DIAGNOSIS• Plaque form of lichen planus: lesions of thrush can be wiped with the help

of gauge• Leukoplakia: history of recent administration of antibiotics will favor the

diagnosis• Genodermatoses: cytological smear should be taken to confirm the

diagnosis• Gangrenous stomatitis: pseudomembrane is dirty in color & not raised

above the surface• Chemical burns: The superficial white material burn of oral mucosa

appears thin and delicate as compared to pseudomembranous candidiasis.

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ACUTE ATROPHIC CANDIDIASISAcute atrophic candidiasis presents as a red patch of atrophic or erythematous raw and painful mucosa, with minimal evidence of the white pseudo-membranous

lesions observed in thrush Depapillation of tongue occurs

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ACUTE ATROPHIC CANDIDIASIS Antibiotic sore mouth, a common form of atrophic

candidiasis, should be suspected in a patient who develops symptoms of oral burning, bad taste, or sore throat during or after therapy with broad-spectrum antibiotics.

Patients with chronic iron deficiency anemia may also develop atrophic candidiasis

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FIGURE: A patient with a history of chronic iron deficiency anemia developed red, raw, and painful areas of the mucosa, diagnosed as acute atrophic candidiasis.

FIGURE: Antibiotic sore mouth in which a red patch of atrophic raw, painful mucosa is seen

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ACUTE ATROPHIC CANDIDIASISDIFFERENTIAL DIAGNOSIS• Chemical burns: focal white area that rub off and underlying condition of

diminished host resistance favors candidiasis• Drug reaction: identification of condition causing diminished host

resistance• Syphilitic mucus patches: discrete small white necrotic lesions on tongue,

palate or lip while candidiasis is diffuse. Skin lesion of syphilis is also present

• Necrotic ulcer and gangrenous stomatitis: ulcer is deeper than candidiasis• Traumatic ulcer: history of trauma is present

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CHRONIC ATROPHIC CANDIDIASISChronic atrophic candidiasis includes • denture stomatitis (denture sore mouth), • angular cheilitis, and • median rhomboid glossitis.

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CHRONIC ATROPHIC CANDIDIASISDENTURE STOMATITIS (Denture Sore Mouth).

It is a common form of oral candidiasis that manifests as a diffuse inflammation of the maxillary denture-bearing areas and that is often (15 to 65% of cases) associated with angular cheilitis

• Candida spp act as an endogenous infecting agent on tissue predisposed by chronic trauma to microbial invasion.

Lesions of chronic atrophic candidiasis have also been frequently reported in HIV-positive patients

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CHRONIC ATROPHIC CANDIDIASISThree progressive clinical stages of denture sore mouth havebeen described.1. First stage consists of numerous palatal petechiae 2. Second stage displays a more diffuse erythema involving

most (if not all) of the denture-covered mucosa3. Third stage includes the development of tissue granulation

or nodularity (papillary hyperplasia) commonly involving the central areas of the hard palate and alveolar ridges.

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FIGURE: A, Numerous palatal petechiae in a patient with an ill-fitting denture. B and C, More diffuse erythema is seen under a partial denture (B) and a full upper denture (C). D, This patient has developed a granular nodular overgrowth of the palate (papillary hyperplasia) secondary to a candidal infection and an ill-fitting denture.

A

B

C

D

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CHRONIC ATROPHIC CANDIDIASISDenture sore mouth is rarely found under a mandibular denture. negative pressure that forms under the maxillary denture

excludes salivary antibody from this region, and yeast may reproduce, undisturbed, in the space between the

denture and mucosa. The closer adaptation of the maxillary denture and palate

may also bring the large number of yeasts adhering to the denture surface into contact with the mucosa.

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CHRONIC ATROPHIC CANDIDIASISANGULAR CHEILITIS.

Angular cheilitis is the term used for an infection involving the lip commissures

• There is frequently a coexistent denture stomatitis, and

• uncommon in patients with a natural dentition.

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CHRONIC ATROPHIC CANDIDIASIS• Other possible etiologic cofactors include

– reduced vertical dimension; – a nutritional deficiency (iron deficiency anemia and vitamin B or folic

acid deficiency) sometimes referred to as perlèche; and– (more rarely) diabetes, – neutropenia, and – AIDS, as well– as co-infection with Staphylococcus and beta-hemolytic Streptococcus.

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FIGURE: Candidal infection of the lip commissures (angular cheilitis).

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CHRONIC ATROPHIC CANDIDIASISMEDIAN RHOMBOID GLOSSITIS.

Erythematous patches of atrophic papillae located in the central area of the dorsum of the tongue are considered a form of chronic atrophic candidiasis

When these lesions become more nodular, the condition is referred to as hyperplastic median rhomboid glossitis. These lesions were originally thought to be developmental in nature but are now considered to be a manifestation of chronic candidiasis.

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FIGURE: Median rhomboid glossitis.

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CHRONIC HYPERPLASTIC CANDIDIASIS• Chronic hyperplastic candidiasis (CHC) includes a variety of

clinically recognized conditions in which mycelial invasion of the deeper layers of the mucosa and skin occurs, causing a proliferative response of host tissue

• Candidal leukoplakia is considered a chronic form of oral candidiasis in which firm white leathery plaques are detected on the – cheeks, – lips,– palate, and – tongue

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CHRONIC HYPERPLASTIC CANDIDIASIS• The differentiation of candidal leukoplakia from other forms

of leukoplakia is based on finding periodic acid–Schiff (PAS)–positive hyphae in leukoplakic lesions

• These patients develop similar lesions around – nails and other skin sites or – alternatively develop only isolated oral lesions.

• CHC also occurs on the dorsum of the tongue and may resemble median rhomboid glossitis

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A B

FIGURE: A, Candidal leukoplakia, a chronic form of candidiasis in which firm red white plaques form, most often in the cheeks. B, Occasionally, the plaques develop in the palate opposite a tongue lesion (kissing lesions).

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FIGURE: Chronic hyperplastic candidiasis occurs on the dorsum of the tongue as a form of median rhomboid glossitis.

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CHRONIC MULTIFOCAL CANDIDIASIS• Patients may present with multiple areas of chronic atrophic

candidiasis. • most often seen in immunocompromised individuals • in patients with predisposing factors such as ill-fitting

dentures. • The changes frequently affect

– dorsum of the tongue & midline of the hard palate (kissing lesions), – commissure area (angular cheilitis), and– denture bearing mucosal surfaces – Smoking may also play an important role in immunocompetent

patients.

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FIGURE: A, B, and C, Chronic multifocal candidiasis presents with multiple areas of chronic atrophic candidiasis, usually involving the palate (midline and under a denture) (A), the commissures (B), and the dorsum of the tongue (C). The tongue lesion is almost healed after 14 days of nystatin therapy. The patient had poor oral hygiene and was a heavy smoker but was not immunocompromised.A

B C

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CHRONIC MUCOCUTANEOUS CANDIDIASIS

Persistent infection with Candida usually occurs as a result of a defect in cell-mediated immunity or may be associated with iron deficiency.

Hyperplastic mucocutaneous lesions, localized granulomas, and adherent white plaques on affected mucous membranes are the prominent lesions that identify chronic mucocutaneous

candidiasis (CMC)

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CHRONIC MUCOCUTANEOUS CANDIDIASIS Two categories of CMC have been described:

1. syndrome-associated CMC and a. familial orb. chronic

2. localized and diffuse CMC.

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CHRONIC MUCOCUTANEOUS CANDIDIASIS The familial form, candidiasis endocrinopathy syndrome

(CES), is a rare autosomal recessive disorder characterized by an onset of CMC during infancy or early childhood, associated with the appearance of hypoparathyroidism,

hypoadrenocorticism, and other endocrine anomalies. Patients develop persistent oral candidiasis and hyperplastic infections

of the nail folds at an early age

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CHRONIC MUCOCUTANEOUS CANDIDIASIS The other syndrome-associated form is chronic candidiasis

associated with thymoma, which appears with other autoimmune abnormalities such as

myasthenia gravis, polymyositis, bullous lichen planus, and hypogammaglobulinemia.

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CHRONIC MUCOCUTANEOUS CANDIDIASIS

• Localized CMC is a variant associated with chronic oral candidiasis and lesions of the skin and nails.

• usually begin within the first two decades of life. • The diffuse variant is characterized by

– randomly occurring cases of severe mucocutaneous candidiasis – widespread skin involvement and – development of Candida granulomas. – It is often associated with other opportunistic fungal and bacterial

infections.

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FIGURE: Chronic mucocutaneous candidiasis manifests as hyperplastic mucocutaneous lesions including granulomas and nodules. A, Localized granulomas and nodules on the tongue. B, The same condition, affecting the skin. C, Adherent white plaques that represent speckled leukoplakia.

A

C

B

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IMMUNOCOMPROMISED (HIV)-ASSOCIATED CANDIDIASIS

• Oral candidiasis is the most frequent opportunistic infection associated with immunocompromised individuals.

• The patients who are on immunosuppressive drug regimens or who have HIV infection, cancer, or hematologic malignancies have an increased susceptibility to oral candidiasis.

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TREATMENT OF ORAL CANDIDIASIS A variety of topical and systemically administered

medications are now available to supplement the older polyene antifungal antibiotics nystatin and amphotericin B.

Treatment should be maintained for 7 days Response to treatment is often good Oral lesions and symptoms may disappear in a fairly short

period (ranging from 2-5 days), but relapse are common because of the underlying immunodeficiency.

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TREATMENT OF ORAL CANDIDIASIS• Topical treatment-

– Clotrimazole—one oral troche (10 mg tab ) dissolved in mouth five times daily

– 1% gentian violet—can be used but it is not ideal because of the superficial necrosis of mucosa and it may produce unsightly staining

– Nystatin preparations-- (7-10 days rinse, 3-4 times daily)– Amphotericin-B—5-10ml of oral solution is used as a rinse and then

expectorated 3-4 times daily– Idoquinol—it has both antifungal and antibacterial properties. When

this is combined with corticosteroid is very helpful in management of angular cheilitis

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TREATMENT OF ORAL CANDIDIASIS• Systemic therapy includes the use of any one of these three:– ketoconazole,– itraconazole, and– fluconazole.

• Fluconazole and amphotericin B may be used intravenously for the treatment of the resistant lesions of CMC and systemic candidiasis.

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TREATMENT OF ORAL CANDIDIASIS• The majority of acute oral Candida infections respond rapidly

to topical nystatin and will not recur, provided that the predisposing factors have also been eliminated– Seven to 21 days’ use of a nystatin rinse three to four

times daily is usually adequate although some resistant cases may require a second course of treatment.

– Nystatin in cream form may also be applied directly to the denture or to the corners of the mouth

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TREATMENT OF ORAL CANDIDIASIS• Patients for whom predisposing factors such as xerostomia

and immunodeficiency cannot be eliminated may need either– continuous or– repeated treatment to prevent recurrences.

• The consumption of yogurt two to three times per week and improved oral hygiene can also help, especially if underlying predisposing factors cannot be eliminated.

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TREATMENT OF ORAL CANDIDIASIS• Better patient compliance and more effective treatment of

both acute and chronic candidiasis can usually be attained by– a once-daily dose of 200 mg of ketoconazole,– 100 mg of fluconazole, or– itraconazole oral suspension (100 to 200 mg/d) for 2

Weeks

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TREATMENT OF ORAL CANDIDIASIS• When these medications are used for this short period, side

effects such as– increased liver enzymes,– abdominal pain, and– pruritus are rare

• Fluconazole is more effective than ketoconazole, but its frequent use can lead to the development of resistance to the drug.

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TREATMENT OF ORAL CANDIDIASIS• Fluconazole therapy for oral candidiasis associated with HIV

infection often results in the development of resistance to fluconazole.

• Itraconazole can be substituted for fluconazole in resistant patients, but fluconazole is still the mainstay of therapy for HIV-associated candidiasis.

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TREATMENT OF ORAL CANDIDIASIS• Fluconazole interacts with a number of other medications and

must be prescribed with care for patients who are using– anticoagulants,– phenytoin,– cyclosporine, and– oral hypoglycemic agents.

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TREATMENT OF ORAL CANDIDIASIS• The simultaneous administration of– ketoconazole (or the related antifungal itraconazole) and– cisapride or antihistamines (terfenadine and astemizole)

• is associated occasionally with ventricular arrhythmias and other serious cardiovascular events.

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Oral candidiasis

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