BDS IV Oral Candidiasis

BDS IV Oral Candidiasis

• Oral candidiasis is a fungal infection in the oral cavity
• Key speaker is Prof. Mohamed Al Ismaili, Head of Oral Surgery
• Learning objectives include classification of oral candidal infections, anti-fungal medication discussion (indications, contraindications, drawbacks), and referral criteria.

Candida

• Candida is a yeast-like fungus commonly found in the oral cavity
• Candida albicans is the most commonly cultured type, associated with disease and opportunistic overgrowth

Opportunistic Mycosis

• Some fungi are normal commensals (e.g., in the mouth, gut, vagina).
• Usually balanced by other microorganisms (like lactobacilli)
• Can become problematic with compromised immune responses (e.g., AIDS, antibiotic use, chemotherapy, radiation, alcoholism).

Predisposing Factors

• Immunodeficiency (e.g., DM, AIDS)
• Immunosuppression (e.g., steroid inhalers)
• Anemia
• Broad-spectrum antibiotics
• Xerostomia (dry mouth)
• Denture wearing
• Smoking (increased risk of thrush)

Classification

• Acute:
  • Acute pseudo-membranous candidosis (thrush)
  • Acute antibiotic stomatitis
• Chronic:
  • Denture-induced stomatitis
  • Chronic hyperplastic candidosis
  • Chronic mucocutaneous candidosis
  • Erythematous candidosis

Acute Pseudomembranous Candidosis (Thrush)

• Characterized by easily scraped-off, creamy patches on an erythematous mucosa (e.g., in the oropharynx).
• Often associated with angular cheilitis or angular stomatitis
• Affects infants, elderly, and immunocompromised individuals
• Neonatal thrush is due to immune system immaturity and birth canal infection

Thrush Pathology

• Smear reveals many Gram-positive hyphae
• Histology shows hyphae invading superficial epithelium, proliferative inflammation, and neutrophils are present ( acute inflammation cells are neutrophils + basophils + esinophils + monocytes + macrophage )
• chronic inflammation cells are Monocytes + macrophage + lymphocytes + plasma cells + fibroblast )

Thrush Management

• Remove the cause (e.g., stop topical antibiotics)
• Control local causes
• Use Nystatin or Amphotericin lozenges
• Address systemic issues if thrush persists (e.g., immunodeficiency, anemia, HIV)
• Systemic fluconazole (1000mg OD x 2 weeks)

Acute Antibiotic Stomatitis

• Frequent or excessive use of antibiotics suppresses normal oral flora
• Results in generalized erythematous and sore oral mucosa
• May show thrush
• Resolves with antibiotic withdrawal or topical antifungal assistance

Angular Stomatitis

• A characteristic sign of candidiasis, with infected saliva leakage at the mouth corners.
• Can be associated with thrush, denture wearers, and chronic hyperplastic candidosis
• Iron deficiency anemia
• Co-infection with Staphylococcus aureus and Beta-hemolytic streptococci are possible.
• Treatment: Treat intra-oral candidal infection and topical fusidic acid cream ( fusidic acid is against staphylococcus aureus )

Denture-Induced Stomatitis

• Deprivation of the underlying mucosa from salivary protective action
• Trauma from occlusion
• Asymptomatic erythema area, possible in conjunction with angular stomatitis
• More common in smokers
• Denture care and hygiene are important to treat this

Denture-Induced Stomatitis: Pathology

• Gram-stained smear shows candidal hyphae and yeast forms
• Histology shows acanthosis and chronic inflammation
• acanthosis : a thickening of the epidermis and elongation of the rete ridges due to thickening of the spinous layer

Denture-Induced Stomatitis: Management

• Improving denture hygiene
• Removing occlusal trauma
• Soaking the denture in 0.1% hypochlorite or 0.2% chlorhexidine overnight
• Topical Miconazole gel on denture fitting surface twice daily
• Treating underlying systemic issues (e.g., anemia).
• Systemic fluconazole, if unresponsive to local treatments

Erythematous Candidosis

• Patchy red mucosal macules due to Candida albicans (often in HIV positive patients with low CD4 counts).
• Affects the hard palate, soft palate, and tongue dorsum
• Linear gingival erythema (this is in attached gingiva without involving papilla) , potential for desquamating gingivitis (will involve both attached gingiva and papilla)
• Treatment: Itraconazole

Chronic Hyperplastic Candidosis

• White, folded plaques behind mouth angles.
• Associated with smokers, poor denture hygiene
• Hyphae invasion of the parakeratin layer

Median Rhomboid Glossitis

• Rhomboid-shaped, erythematous patch on midline dorsal tongue.
• Usually asymptomatic.
• Epithelial hyperplasia with neutrophils in the parakeratin layer.

Antifungal Drugs

• Polyenes: (e.g., Amphotericin B, Nystatin)

  • Work on cell membranes, altering ergosterol function and leading to cell membrane disruption
  • Amphotericin B is given intravenously or topically (poor oral absorption); not well-tolerated but effective in systemic infections.
  • Nystatin is topical only.

• Azoles: (e.g., Ketoconazole, Miconazole, Fluconazole, Itraconazole)

  • Inhibit ergosterol synthesis.
  • Often preferable to polyenes for oral infections
  • Fluconazole is well-tolerated and commonly prescribed for systemic candidosis; high CSF penetration.
  • Miconazole and Ketoconazole are often prescribed topically.
  • Itraconazole has poor absorption and does not cross the blood-brain barrier, so it is less-preferred for CNS issues.
  • Imidazoles (e.g., Ketoconazole, Miconazole, Fluconazole, Itraconazole) are frequently used, due to their fungistatic action against fungi and dermatophytes, and their resistance to changes in 14-demethylase.

• miconazole and fluconazole interact with warfarin and with statins (myopathy )

This quiz focuses on oral candidiasis, a fungal infection in the oral cavity. Led by Prof. Mohamed Al Ismaili, the quiz covers classification, antifungal medications, and the impact of various predisposing factors. It aims to enhance understanding of opportunistic mycosis and its management in dental practice.