Denture-Related Stomatitis and Oral Candidiasis Quiz

Candidiasis Overview

• Candidiasis encompasses a group of yeast-like fungal infections affecting skin and mucous membranes.
• Oral candidiasis, specifically, is categorized into four types: acute pseudomembranous (thrush), acute atrophic (erythematous), chronic hyperplastic, and chronic atrophic (erythematous).

Predominant Oral Species

• C. albicans is the most frequent oral species, followed by Candida tropicalis, Candida glabrata, Candida parapsilosis, Candida krusei, and other Candida species (less common).
• Some Candida species are rare and transient.

Predisposing Factors

• Local factors: xerostomia (dry mouth), caused by medications or radiotherapy, antibiotic therapy (particularly broad spectrum), corticosteroids, heavy smoking, and dental appliances.
• Systemic factors: poorly controlled diabetes mellitus, extremes of age, nutritional deficiencies (iron, vitamin B12, folic acid), immunosuppressive drugs (corticosteroids, cytotoxic chemotherapy), and immunodeficiency (hereditary or acquired, like HIV).

Diagnostic Tests

• Smear and stain: a sample from the affected area is stained using Gram's stain or PAS (periodic acid-Schiff) to visualize Candida hyphae.
• Culture: swabs and oral rinses are cultured to identify the specific Candida species.
• Biopsy and histopathology: a biopsy examination allows for confirming chronic hyperplastic candidiasis and checking for dysplasia (precancerous changes).

Management of Candidiasis

• Lifestyle modifications: avoiding or reducing smoking, treating local predisposing causes (like xerostomia), and improving oral hygiene (chlorhexidine has anti-candidal activity).
• Topical antifungals: medications like nystatin and miconazole gel are often applied to the affected areas, frequently placed on dentures.
• Systemic antifungals: fluconazole is for treating resistant cases.
• Prophylactic antifungals: necessary for patients with HIV, cancer chemotherapy, immunosuppressive therapy, or prolonged antibiotic use.

Acute Pseudomembranous Candidiasis (Thrush)

• Definition: Candida albicans accumulates on the oral mucosa, causing a characteristic white-fleck appearance resembling a bird.
• Causes: observed in healthy individuals when oral microflora is altered by antibiotics, corticosteroids, or xerostomia. Frequently complicates corticosteroid inhaler use.

Symptoms and Clinical Features

• Creamy white lesions on the tongue, inner cheeks, and sometimes on the roof of the mouth, gums, and tonsils.
• Lesions resemble cottage cheese and can sometimes be painful or bleed slightly when touched.
• Severe cases, lesions can spread to the esophagus, causing difficulty swallowing or the feeling of food getting stuck.

Tests and Diagnosis

• Diagnosis is typically made by observing the visible lesions.
• Microscopic examination of a sample is occasionally used to confirm.
• More serious cases may require throat cultures, endoscopic examinations, or barium swallows.

Treatment and Drugs

• Treatment goals are to prevent fungal spread and balance gut bacteria.
• Children: adding unsweetened yogurt and antifungal medications.
• Infants and nursing mothers: mild topical antifungal medications or oral creams.
• Healthy adults: using unsweetened yogurt, acidophilus capsules/liquids, or antifungal medications.
• Weakened immune systems: antifungal medications in various forms (lozenges, tablets, or swish-and-swallow liquids).

Atrophic (Erythematous) Candidiasis

• Characterized by red lesions.
• In some cases, can precede or be a consequence of pseudomembranous candidiasis.
• Related conditions include denture-related stomatitis, antibiotic-induced stomatitis, and median rhomboid glossitis, especially in HIV infection.

Denture-related Stomatitis

• Mild inflammation and erythema beneath dentures, typically complete upper dentures.
• Erythematous area restricted to the denture-wearing zone.
• Rare complications include angular stomatitis and papillary hyperplasia of the palate.
• Classification (Newton's types) into localised inflammation or pinpoint erythema (type 1), a more diffuse erythema involving parts of or entire denture-covered mucosa (type 2), and a granular type of inflammation commonly affecting the hard palate and alveolar ridge (type 3).

Diagnosis of Denture-related Stomatitis

• Clinical assessment—inspection of erythema and oedema on the palatal mucosa under dentures.
• Confirmation via a smear of the palate (periodic acid-Schiff stain) may reveal Candida.

Treatment of Denture-related Stomatits

• Address any underlying systemic issues.
• Correct any mechanical factors (e.g., denture fit).
• Apply topical antifungals (nystatin, miconazole).
• Systemic antifungals (fluconazole) in severe cases.

Median Rhomboid Glossitis (MRG)

• Characterised by a depapillated, typically reddish- or white-colored, painless, well-defined, rhomboidal area in the middle of the tongue's surface.
• Uncommon and typically found in adults.

Diagnosis of MRG

• Generally a clinical diagnosis.
• Biopsy might be necessary in certain cases for confirming the diagnosis.

Treatment of MRG

• No treatment is usually necessary.
• Antifungal therapy (topical or systemic) may help reduce inflammation related to Candida infection.

Erythematous Candidiasis in HIV Disease

• Uncommon finding.
• Observed as irregular erythematous patches generally on the tongue's surface, hard palate, or buccal mucosa.
• May also present as 'thumbprint' lesions in the palate region.

Diagnosis of Erythematous Candidiasis in HIV Disease

• Often diagnosed clinically.
• Rarely, smears or culture might be required if unsure based on the clinical evaluation.

Chronic Hyperplastic Candidiasis (Candidal Leukoplakia)

• Persistent white lesion on the commissures of the oral mucosa.
• Associated with Candida albicans and systemic co-factors like vitamin deficiency or immune suppression.
• Without treatment, some lesions may show dysplasia, potentially progressing into carcinomas.

Diagnosis of Chronic Hyperplastic Candidiasis

• Clinically the lesion can be identified.
• A biopsy can distinguish it from other white lesions. Candida hyphae are confirmed using periodic acid-Schiff (PAS) stain.
• Additional investigation to check for dysplasia is required.

Treatments and Prognosis of Chronic Hyperplastic Candidiasis

• Treatment strategies include systemic anti-fungal therapy (fluconazole).
• Overall prognosis and risk factor of progression to a carcinoma vary. Possible variables include lesion characteristic and degree of dysplasia.

Chronic Mucocutaneous Candidiasis (CMC)

• CMC is a serious condition that represents a group of overlapping syndromes, characterized by persistent, widespread, and often severe infections with Candida that affect the skin, nails, and mucous membranes.