Oral candidiosis: A Review

LIBYAN INTERNATIONAL MEDICAL UNIVERSITY

FACULTY OF DENTISTRY

Ziad S. Abdul Majid Oral Medicine

ORAL CANDIDIOSIS

: A REVIEW

Outlines

Overview.

Microbiologic point of view.

Factors which increase susceptibility of oral candidosis.

Classification of oral candidosis.

Differential diagnosis.

Investigations.

Management.

Clinical case presentation.

References.

Overview

Oral Candidiasis is one of the common fungal

infection affecting the oral mucosa.

These lesions are caused by the yeast Candida

albicans.

Candida albicans

Are found in small numbers in the

Commensal flora (mouth, gastrointestinal tract

,vagina ,skin).

30% to 50% people carry this organism.

Rate of carriage increases with age of the

patient.

Candida albicans are recovered from 60% of

dentate patients mouth over the age of 60

years.

Virulent factors of Candida albicans

The ability to adhere to host tissue and

prostheses and form biofilms.

The potential to switch ( e.g. rough to smooth

colony formation ) and modify the surface

antigens.

The ability to form hyphae that helps in tissue

invasion.

Extracellular phospholipase ,proteninase and

haemolysin production which break down

physical defence barriers of the host .

There are three general factors which helps

the Candida albicans infection to develop in

the patient’s body.

They are:

1. Immune status of the patient.

2. Oral mucosal environment.

3. Strain of Candida albicans.

Main factors which increase susceptibility of oral candidiasis are:

( Samaranayake et al 2007).

Chronic local irritants.

Ill fitting appliance.

Inadequate care of appliance.

Disturbed oral ecology or marked changes in

the oral flora by antibiotics , corticosteroids,

xerostomia.

Dietary factors.

Immunological and endocrine disorders ( e.g.

Diabetes mellitus)

Cont.

Malignant and chronic diseases.

Severe blood dyscrasias.

Radiation to the head and neck.

Abnormal nutrition.

Age ( e.g. very young or very old )

Hospitalization.

Oral epithelial dysplasia.

Heavy smoking.

Classification Of Oral

Candidosis

OLD Classification

Acute candidosis:

i. Thrush.

ii. Acute antibiotic stomatitis.

Chronic candidosis:

i. Denture-induced stomatitis.

ii. Chronic hyperplastic candidosis.

iii. Chronic mucocutaneous candidosis.

iv. Erythematous candidosis.

Angular stomatitis (common to all types of oral candidosis)

OLD Classification :

Newest Classification

(Greenberg et al. 2008)

Primary oral candidosis Acute forms:• Pseudomembranous

• Erythematous

Chronic forms:• Hyperplasic (nodular or plaque-like)

• Erythematous

• Pseudomembranous

Candida-associated lesions:• Denture stomatitis

• Angular cheilosis

• Median rhomboid glossitis

Keratinized primary lesions with candidal super infection:

• Leukoplakia

• Lichen planus

• Lupus erythematosus

Secondary oral candidosis

Oral manifestations of systemic

mucocutaneous candidosis:

• Thymic aplasia.

• Candidosis endocrinopathy syndrome.

• Acquired immune deficiency syndrome (AIDS).

Pseudomembranous candidosis

Thrush forms soft, friable, and creamy colored

plaques on the mucosa .

The distinctive feature is that they can be

wiped off, to expose an erythematous

mucosa.

The plaques consist of necrotic material,

desquamated epithelial cells, fibrin and fungal

hyphae.

Their extent varies from isolated small flecks to

widespread confluent plaque.

Cont.

This form of candidosis is most common in immunocompromised individuals, in extremes of age, poorly controlled diabetes mellitus, HIV infections.

patients taking corticosteroids, anti-proliferative or psychotropic medications and patients on long-term broad-spectrum antibiotic therapy.

Smear shows many Gram-positive hyphae.

Histology shows hyphae invading superficial epithelium with proliferative and inflammatory response.

Cont.

Rarely, persistent thrush is an early

sign of chronic mucocutaneous

candidosis such as candida-

endocrinopathy syndrome.

Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

Acute antibiotic stomatitis

This can follow overuse or topical oral use of antibiotics, especially tetracycline, suppressingnormal, competing oral flora.

Clinically, the whole mucosa is red and sore. Flecks of thrush may be present.

Resolution may follow withdrawal of the antibiotic but is accelerated by topical antifungal treatment.

Generalised candidal erythema, which is clinically similar, can also be a consequence of xerostomia which promotes candidal infection. It is a typical complication of Sjogren's syndrome.

Erythematous candidosis

This term applies to patchy red mucosal

macules due to C. albicans infection in HIV-

positive patients.

Favoured sites, in order of frequency, are the

hard palate, dorsum of the tongue and soft

palate.

Hyperplasic candidosis

presents as a well demarcated, slightly elevated,

adherent white lesion of the oral mucosa ranging

from small translucent lesions to large, dense

opaque plaques.

It may present as one of two variants: as an

isolated, adherent white plaque (homogeneous

form) Or as multiple white nodules on an

erythematous background (nodular or speckled

form).

The most common location of such lesions is the

post-commissural buccal mucosa, and less

frequently the tongue, and the palate posterior to

upper dentures.

Recognition of such

lesions is important as

they have been

associated with a higher

degree of dysplasia and

malignancy than

leukoplakia with no

Candidal association.

Cont.


Denture stomatitis

A well-fitting upper denture or even an orthodonticplate cuts off the underlying mucosa from theprotective action of saliva.

Cause lesions manifested as symptomless area oferythema.

Similar inflammationis not seen under the moremobile lower denture which allows a relatively freeflow of saliva beneath it.

Angular stomatitis is frequently associated andmay form the chief complaint.

Smoking also appears to increase susceptibilityto this infection.

In the past, denture-induced stomatitis was

ascribed to 'allergy' to denture base material but

there is no foundation for this fancy.

Methylmethacrylate monomer is mildly sensitising

but even the rare individuals sensitised to it can

wear the polymerised material without any

reaction.

Cont.

Angular cheilosis

Caused by leakage of candida infected saliva at theangles of the mouth. It can be seen in infantilethrush, denture wearers or in association withchronic hyperplastic candidosis.

Clinically, there is mild inflammation at the anglesof the mouth; In elderly patients with denture-induced stomatitis, inflammation frequently extendsalong folds of the facial skin extending from theangles of the mouth .

These folds have frequently but unjustifiably beenascribed to 'closed bite', but in fact, are due tosagging of the facial tissues with age.

Median rhomboid glossitis

characterized by a symmetrical, erythematous,

elliptical or rhomboid-like area located on the

posterior dorsal surface of the tongue just

anterior to the circumvallate papillae

This area represents atrophy of the filiform

papillae.

Histologically fungal hyphae are seen invading

the superficial layers of parakeratotic epithelium

with hyperplastic rete pegs.

Fungiform and filiform papillae are usually

absent.

Differential

Diagnosis

Differential diagnosis based on clinical presentation

(Neville et al)

White lesions

(can be wiped off)

• Erythematous

(atrophic)

candidosis

•Traumatic erythema

• Erythema migrans

• Thermal erythema

• Erythroplakia

• Erosive lichen

planus

• Mouthwash or

toothpaste

reaction

• Chronic

hyperplastic

candidosis

• Leukoplakia

•Tobacco keratosis

• Lichen planus

• Pseudomembranous

candidosis

• Materia alba

• Coated tongue

• Thermal or chemical

injury

• Mouthwash or

toothpaste

reaction

White lesions

(cannot be wiped

off)

Red lesions

INVESTIGATIONS

Investigations

When the clinical diagnosis is unclear,

additional tests, such as exfoliative cytology,

culture, or tissue biopsy, may be useful to

confirm a diagnosis.

Laboratory investigations

Recognition of the pathogen in tissue by

microscopy

Isolation of the causal fungus in culture

The use of serological tests

Detection of the fungal DNA by polymerase

chain reaction (PCR)

Gram stain of a surface scraping from a patient with pseudomembranous

candidiasis showing yeast spores and mycelia among epithelial cells


Sabouraud agar culture demonstrating growth of C.

albicans


PAS-stained biopsy demonstrating candidal hyphae and

pseudomycelia

Management Strategies

Treatment goals

The goals of treatment are to identify and

eliminate possible contributing factors,

prevent systemic dissemination, and

eliminate any associated discomfort.

Pharmacological treatment should be

tailored to the individual patient, based on his

or her current health status and the clinical

presentation and severity of infection.

Management

Confirm diagnosis with smear (most types) or

biopsy (chronic hyperplastic candidosis)

unless presentation is typical.

Check history for predisposing causes which

may require treatment.

If candidosis is recurrent or not responsive to

treatment, test for anemia, folate and vitamin

B12 deficiency and perform diabetes

investigations.

If a Denture is worn:

1. Cease night-time wear.

2. Check denture hygiene.

3. Soak denture overnight in

antifungal ,(dilute hypochlorite,

chlorhexidine mouthwash) or,

less effective, apply miconazole

gel to denture fit surface while

worn.

If a Steroid inhaler is used, check it is being

used correctly, preferably with a spacer.

Advise to rinse mouth out after use.

Cont.

Pharmacological treatment

NN

H3C

O

O

OO

Cl

N

N

ClH

Pharmacological treatmentImmunosuppression

or

otherwise resistant

to

treatment

Angular

stomatitis

Chronic

hyperplastic

form

Generalised acute or

chronicType

fluconazole

50 mg/day for 7-14

days

Or

or itraconazole

(100 mg/day

for 14 days)

Or

Ketokenezole

Miconazole

gel 24 mg/ml

QDS 10-14 d

Or

or fusidic

acid cream

Miconazole

gel

24 mg/ml.

Apply QDS

Or

For recurrent

infection in

white patches

fluconazole

may be

required

simultaneously

Nystatin 100 000

units QDS for 7-10

days as suspension

Or

Amphotericin 10 mg

QDS as lozenges or

suspension 10-14

days.

Drug of

choice

&

regime

References

1. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

2. Neville, Oral and Maxillofacial Pathology, 2nd Ed

3. ORAL CANDIDIASIS: A REVIEW ; YUVRAJ SINGH DANGI1, MURARI LAL

SONI1, KAMTA PRASAD NAMDEO1International Journal of Pharmacy and

Pharmaceutical Sciences 2010

4. Oral candidosis Quintessence Int 2002

5. Oral Candidiasis – A Review ;Prasanna Kumar Rao Scholarly Journal of

Medicine 2012

6. Oral fungal infections: an update for the general practitioner ; CS Farah,* N

Lynch,* MJ McCullough , Australian Dental Journal 2010

Oral candidiosis: A Review

Education

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