Candidiasis

Predisposing factors:

Local factors

¨ Xerostomia from drugs or radiotherapy

¨ Antibiotic therapy, particularly broad-spectrum agents

¨ Corticosteroids

¨ Heavy Smoking

¨ Dental appliances

Systemic factors

¨ Poorly controlled diabetes mellitus (neutrophil leukocyte defects)

¨ Extremes of age

¨ Nutritional deficiencies – Iron, Vitamin B12, Folic acid

¨ Immunosuppressive drugs – corticosteroids, cytotoxic chemotherapy

 

¨ Immunodeficiency – Hereditary / Acquired (HIV)  SEE picture on right

 

Classidication of Candidiasis:

 

Acute Candidiasis

¨ Pseudomembranous  (Thrush)

             White/creamy plaques, easy to wipe off – leaves erythematous base

             Often palate – junction hard/soft, fauces. Can be chronic if immunocompromised

¨ Erythematous/Atrophic

Presents as red lesions. Can be seen in :-     

Denture-related stomatitis (mild inflammation and erythema of mucosa beneath denture, usually asymptomatic)

 

 

 

 

 

 

 

 

 

 

 

AB-induced stomatitis (generalised mucosal erythema following broad-spectrum antibiotics, eliminates normal oral flora)

 

Median Rhomboid glossitis (depapillated rhomboidal area in centre line of dorsum of tongue, anterior to circumvallate papillae, usually asymptomatic)      

 

 

 

 

 

 

Chronic Candidiasis

¨ Hyperplastic (Candidal Leukoplakia)

Persistent white lesions, often at commissures or buccal mucosa, cannot rub off, 50% speckled, varying levels of epithelial dysplasia and recognised risk of malignant transformation (between 9 and 40%).

 

 

 

 

 

¨ Mucocutaneous Candidiasis (CMC) Syndromes

             Localised – oesophagitis, iron deficiency with persistent oral candidiasis

             Diffuse (Candida Granuloma) – granulomas, susceptibility to bacterial infections,            

             Endocrinopathy Syndrome – pernicious anaemia, hypoparathyroidism, hypoadrenocorticism,              diabetes             

             Thymoma – myasthenia gravis, aplastic anaemia, defect of cell mediated immunity

¨ Erythematous/Atrophic

 

Angular Stomatitis/Cheilitis

             Multifactorial cause:- skin folding due to age, diabetes mellitus, nutritional deficiencies, denture wearing

             Inflammation at commissures of lips, erythema possibly with yellow crusting

             Rx. intra-oral infection of candida

             Miconazole gel/cream effective for candida and staph. and strep., Fusidic acid cream effective for staph. aureus

 

Diagnostic tests

¨ A smear from the affected region should be taken and stained (Gram’s stain or PAS) -  see candida hyphae

¨ A swab and an oral rinse should also be taken and sent for culture

¨ Biopsy and histopathological examination is necessary to confirm chronic hyperplastic candidiasis – examine for possible dysplasia

Management

¨ VITAL to consider why candidal infection has arisen – underlying systemic conditions? Always consider HIV in adult male where no other detectable cause

¨ Control of any local causes/predisposing factors —antibiotic therapy, anaemia, xerostomia, folic acid deficiencies, smoking, may be enough to resolve the lesions.

¨ Topical use of antifungals – Nystatin pastilles/suspension, or Amphotericin lozenges should allow the oral microflora to return to normal.

¨ Miconazole gel can be coated onto the base of the denture, TDS, while the denture is being worn, for denture-induced stomatitis, and continued 1—2 weeks, until the inflammation has cleared and C.albican is eliminated.

¨ Elimination of C.albicans from the denture base is important and can be achieved by soaking the denture in 0.1% hypochlorite overnight. Topical anti-fungals can only gain access to the palate if the patient leaves their dentures out while the tablets are allowed to dissolve in the mouth.

¨ Systemic Itraconazole and Fluconazole, can be used for resistant cases.

Candidal species are carried as normal oral commensals by 50% of the population. Candida albicans is the most frequently isolated strain and can cause a spectrum of lesions.