Candidal Lesions PDF

Oral candidiasis  Candidosis describes a group of yeast like fungal infections involving the skin and mucous membranes. bicans.  Classification of oral candidosis  (1) acute pseudomembranous candidosis (thrush),  (2) acute atrophic (erythematous) can...

Oral candidiasis  Candidosis describes a group of yeast like fungal infections involving the skin and mucous membranes. bicans.  Classification of oral candidosis  (1) acute pseudomembranous candidosis (thrush),  (2) acute atrophic (erythematous) candidosis,  (3) chronic hyperplastic candidosis, and  (4) chronic atrophic (erythematous) candidosis.  The most dominant oral species, in decreasing order of frequency, are:  C. albicans  Candida tropicalis.  Candida glabrata  Candida parapsilosis  Candida krusei  other Candida species  other which are rare and transient. 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  Extremes of age  Nutritional deficiencies – Iron, Vitamin B12, Folic acid  Immunosuppressive drugs – corticosteroids, cytotoxic chemotherapy  Immunodeficiency – Hereditary / Acquired (HIV( 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 of candidiasis  Avoid or reduce smoking.  Treat any local predisposing cause such as xerostomia.  Improve oral hygiene; chlorhexidine has some anti-candidal activity. Management Topical use of antifungals – Nystatin. Miconazole gel can be coated onto the base of the denture,continued 1—2 weeks, until the inflammation has cleared and C.albican is eliminated. 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 Fluconazole, can be used for resistant cases  Those at greatest need for such prophylactic antifungals include patients:  with HIV disease  receiving cancer chemotherapy  on immunosuppressive therapy  on prolonged antibiotic therapy (1)Acute pseudomembranous candidosis (thrush)  Definition  Oral thrush is a condition in which the fungus Candida albicans accumulates on the lining of your mouth.  Thrush (acute pseudomembranous candidiasis) is the term used for the multiple white-fleck appearance of acute candidiasis, which resembles the appearance of the bird with the same name  Thrush may be observed in healthy or in persons in whom antibiotics, corticosteroids, or xerostomia disturb the oral microflora.  Oropharyngeal thrush occasionally complicates the use of corticosteroid inhalers. Immune defects, especially HIV infection, immunosuppressive treatment, leukemias, lymphomas, cancer, and diabetes, may predispose patients to candidal infection.  Causes  Oral thrush and other candida infections occur when immune system is weakened by disease or drugs such as prednisone, or when antibiotics disturb the natural balance of microorganisms in the body.  These illnesses may make more susceptible to oral thrush infection:  Chronic mucocutaneous candidiasis.  HIV/AIDS.  Cancer  Diabetes mellitus  Symptoms and clinical features :  Oral thrush usually produces creamy white lesions on the tongue and inner cheeks and sometimes on the roof of the mouth, gums and tonsils.  The lesions, which resemble cottage cheese, Lesions develop into confluent plaques that resemble milk curds, can be painful and may bleed slightly when rubbed or scraped.  In severe cases, the lesions may spread downward into esophagus — the long, muscular tube stretching from the back of your mouth to stomach (Candida esophagitis). If this occurs, it experience difficulty swallowing or feel as if food is getting stuck in throat.  Tests and diagnosis  Oral thrush can usually be diagnosed simply by looking at the lesions, but sometimes a small sample is examined under a microscope to confirm the diagnosis.  In older children or adolescents who have no other risk factors, an underlying medical condition may be the cause of oral thrush  Thrush that extends into the esophagus can be serious. To help diagnose this condition, one or more of the following tests:  Throat culture.  Endoscopic examination.  Barium swallow.  Treatments and drugs  The goal of any oral thrush treatment is to stop the rapid spread of the fungus, but the best approach may depend on your age and the cause of the infection.  Treating oral thrush in children adding unsweetened yogurt to child's diet to help restore the natural balance of bacteria. antifungal medication.  Treating oral thrush in infants and nursing mothers mild antifungal medication for baby and an antifungal cream for the breasts.  Treating oral thrush in healthy adults eating unsweetened yogurt or taking acidophilus capsules or liquid. Some brands need to be refrigerated to maintain their potency. Yogurt and acidophilus don't destroy the fungus, but they can help restore the normal bacterial flora in the body. If this isn't effective, doctor may prescribe an antifungal medication.  Treating oral thrush in adults with weakened immune systems antifungal medication, which may come in one of several forms, including lozenges, tablets or a liquid that you swish in the mouth and then swallow. (2) Atrophic (erythematous) candidosis Erythematous or atrophic candidiasis is candidiasis presenting as red lesions. Red lesions may be seen in denture- related stomatitis, antibiotic-induced stomatitis, sometimes in median rhomboid glossitis and, in HIV infection, may preceede pseudomembranous candidiasis, or may arise as a consequence of persistent acute pseudomembranous candidiasis. 1-Denture-related stomatitis Introduction Denture-related stomatitis (denture sore mouth; chronic atrophic candidiasis) consists of mild inflammation and erythema of the mucosa beneath a denture, usually a complete upper denture. Clinical features  The characteristic presenting features of denture-related stomatitis are:  chronic erythema and oedema of the mucosa that contacts the fitting surface of the denture, usually a complete upper denture; the mucosa below lower dentures is rarely involved  erythema restricted to the denture- wearing area  usually no symptoms  uncommon complications, which include:  angular stomatitis  papillary hyperplasia of the palate. Classification  Denture-related stomatitis has been classified into three clinical types (Newton's types), increasing in severity:  Type 1: a localised simple inflammation or a pinpoint hyperaemia.  Type 2: an erythematous or generalised simple type presenting as more diffuse erythema involving a part of, or the entire, denture-covered mucosa.  Type 3: a granular type (inflammatory papillary hyperplasia) commonly involving the central part of the hard palate and the alveolar ridge.  Diagnosis  The clinical presentation of erythema and oedema on the palatal mucosa covered by the denture base (but not beyond) is a diagnostic finding.  A smear of the palate stained periodic acid-Schiff can demonstrate the presence of Candida species.  Treatment:  topical application of nystatin or miconazole.  Miconazole as gel, varnish, lacquer and chewing gum.  Systemic antifungal drugs (i.e. fluconazole, itraconazole, ketoconazole), are almost exclusively reserved for patients with systemic factors that condition the development and persistence of candidosis, such as immunosuppression or diabetes.  Angular cheilitis 2 Angular stomatitis  Introduction Angular cheilitis is inflammation at the commissures(angles) of the lips.  Incidence :Is common.  AGE:it occures mostly in adults.  SEX: it occures in both sexes.  GEOGRAPHIC :no known geographic incidence. ANGULAR STOMATITIS Predisposing factors  Angular stomatitis is predisposed by what are known as the 3Ds:  denture-wearing and disorders that predispose to candidiasis: -dry mouth -tobacco smoking.  Deficiency states such as : -iron deficiency -hypovitaminoses especially B  - malabsorption states (e.g Crohn,s disease). - possibly zinc deficiency,but only rarly defects in immunity such as in Down, syndrome,HIV infection, diabetes,cancer and others.  Disorders where the lips are enlarged, such as orofacial granulomatosis, Crohn,s disease and DOWN syndrome. Aetiology  A number of factors (infective,mechanical,nutritional or immunological) may be implicated alone or in combination.  Angular chelitis is most often chronic, seen in the elderly, and due to infective and\or mechanical causes.  Candida albicans and streptococcus aureus are often isolated from the lesions.  Infective agents can be isolated in up to 54% of lesions, with mainly candida or staphylococci being isolated. (saliva - dentures).  Mechanical factors may play a part in the edentulous patient who does not wear or who has inadequate dentures.  Deficiencies of haematinic (factors required for blood formation which include iron, vitamin B and folic acid). Angular stomatitis is, very occasionally, an isolated initial sign of anemia or vitamin dficiency (B12). Immune deficiency such as in diabetes, HIV disease may result in angular cheilitis associated with candidiasis.  In uncommon conditions where the lips are enlarged, such as orofacial granulomatosis, up to 20% of idivisuals have angular stomatitis.  Clinical features  Soreness,erythema and fissring affect the angles of the mouth symmetrically.  Angular chelities most commonly presents as roughly triangular areas of erythema and oedema at both commissures. Atrophy, erythema, ulceration,crusting,and scarring may be seen.  Recurrent exudation are frequent.  Commonly,there is associated denture-related stomatitis.  Rarly ,there is also commissural leukoplakia intraorally diagnosis  Thisis usually a clinical diagnosis, made by clinical examination alone. Inspection may reveal palatal erythema caused by associated denture-related stomatitis, usually due to candidasis.  An underling nutritional deficiency may be revealed by a depapillated tongue in iron deficiency, a depapillated GLOSSY RED TONGUE IN FOLATE DEFICIENCYor depapillated tongue in vit B deficiency.  Angular cheilitis accompanied by alopecia,diarrhoea and non-specific oral ulceration, most commonly of the tongue and buccal mucosa, may suggest ZINC DEFICIENCY.  In all cases in denture wears, CANDIDA should be sough not only in the lesion but also beneath the denture. Management  Management of angular chelities is sometimes difficult and may need to be prplonged.  Tobbaco habits should be stopped  Eliminate any underlying systemic predisposing factors. Underlying systemic disease must be sought and treated, and a course of oral iron and vit B supplements may be helpful.  if infection is the cause of angular cheilitis, treatment will only be effective if the underling disease process is also being treated.  The skin lesions should be swabbed.  Permanent cure can be achieved only by eliminating candidiasis as well as the growth of CANDIDA beneath  Recurence of angular chelities must be prevented by eliminting organism from their reservoir.  Angular stomaties should be treated with a topical antifungal ( e.g miconazole).  STAPHYLOCOCCUS infection can be cleared with topical antibiotics such as fusidic acid ointment or cream used at least four times daily.  Mixed infection of CANDIDA and STAPHYLOCOCCUS respond best to topical miconazole.  Mechanical predisposing factors should be corrected. A change in dentures may be necessary, new dentures which correct facial contour may help.  In rare intractable cases, surgery or ,occasionally, collagen injections may useful in trying to restore normal commissural anatomy. 3-Median rhomboid glossitis  Median rhomboid glossitis (MRG), or glossal central papillary atrophy, is a depapillated rhomboidal area in the centre line of the dorsum of the tongue.  Incidence It is uncommon.  Age : It can occur at any age.  Sex : It can occur in either sex.  Geographic : It has no known geographic incidence. Clinical features  MRG is only rarely sore, but is more usually detected incidentally by the patient or dentist. It is characterised by:  An area of papillary atrophy which is usually reddish or red and white, or occasionally white. It is elliptical or rhomboidal in shape, symmetrically placed centrally at the midline of the tongue, just anterior to the circumvallate papillae.  Clinical feature:  less than 2 cm. in greatest dimension and most demonstrate a smooth, flat surface,  have surface raised more than 5 mm, above the tongue surface, and occasional lesions are located somewhat anterior to the usual location.  Pathology and Differential Diagnosis  shows a smooth or nodular surface covered by atrophic stratified squamous epithelium overlying a moderately fibrosed stroma with somewhat dilated capillaries.  Fungiform and filiform papillae are not seen,  A mild to moderately intense chronic inflammatory cell infiltrate may be seen within subepithelial and deeper fibrovascular tissues.  Chronic candida infection may result in excess surface keratin, Diagnosis  MRG is usually a clinical diagnosis. Biopsy is rarely indicated; histology shows irregular epithelial hyperplasia, which resembles, but is not, a carcinoma (because of the pseudoepitheliomatous hyperplasia).  Rarely, there is a need for blood picture, smears for fungal hyphae or culture.  Treatment and Prognosis  No treatment is necessary for median rhomboid glossitis, but nodular cases are often removed for microscopic evaluation.  Recurrence after removal is not expected,  Antifungal therapy (topical troches or systemic medication) will reduce clinical erythema and inflammation due to candida infection.. 4-Erythematous candidiasis in HIV disease  Incidence: It is uncommon.  Age : It can occur at any age.  Sex : It can occur in either sex.  Geographic : It has no known geographic incidence. Clinical features  The clinical presentation is of irregular erythematous macules and/or patches, generally on the dorsum of the tongue, palate or buccal mucosa.  Lesions are often seen in the central palate and sometimes termed 'thumbprint lesions'.  Lesions on the dorsum of the tongue present as glossitis or depapillated areas.  There can be an associated angular stomatitis. Diagnosis This is a clinical diagnosis; biopsy is only rarely indicated. Occasionally there is a need for smears or culture. Management  Tobacco habits should be stopped.  Antiretroviral treatment.  Since the lesions in HIV disease may prove poorly responsive to the antifungal drugs, systemic fluconazole is usually indicated. Chronic hyperplastic candidiasis (3)Chronic hyperplastic candidosis (candidal leukoplakia):  is a variant of oral candidosis that typically presents as a white patch on the commissures of the oral mucosa.  The major etiologic :Candida albicans, systemic co-factors, such as vitamin deficiency and generalized immune suppression ,  If the lesions are untreated, a minor proportion may demonstrate dysplasia and develop into carcinomas..  Chronic hyperplastic candidiasis, or candidal leukoplakia is a persistent white lesion, characterised histologically by parakeratosis and chronic intraepithelial inflammation with fungal hyphae invading the superficial layers of the epithelium.  Incidence: It is uncommon.  Age : It is found in adults.  Sex: It can occur in either sex.  Geographic: It can be found worldwide. Clinical features  Candidal leukoplakias are chronic, discrete raised lesions that vary from small, palpable, translucent, whitish areas to large, dense, opaque plaques, hard and rough to the touch (plaque-like lesions). Homogeneous areas or speckled areas can be seen, which do not rub off (nodular lesions).  Candidal leukoplakias are non- homogeneous 'speckled' leukoplakias in up to 50%.  Candidal leukoplakias usually occur on the buccal mucosa on one or both sides, mainly just inside the commissure, less often on the tongue. Diagnosis  Candidal leukoplakias can be indistinguishable from other leukoplakias except by biopsy when Candida hyphae can be seen after staining with periodic acid Schiff (PAS). Candidal leukoplakia should therefore be biopsied both to:  distinguish it from other non-candidal lesions  examine for possible dysplasia. Management  From 9% to 40% of candidal leukoplakias may develop into carcinomas.  Factors influencing the prognosis may include:  risk factors, such as tobacco and alcohol use  whether the lesion is speckled (more dangerous) or homogeneous  the presence (more dangerous) and degree of epithelial dysplasia  Treatment:  A case of candidal leukoplakia (chronic hyperplastic candidosis) treated with the systemic antifungal agent, fluconazole, is reported. Dramatic clinical and histopathological resolution of the condition occurred following 11 days of drug therapy (4)Chronic mucocutaneous candidosis  Chronic mucocutaneous candidiasis (CMC) is the label given to a group of overlapping syndromes that have in common a clinical pattern of persistent, severe, and diffuse cutaneous candidal infections. These infections affect the skin, nails and mucous membranes.:  Treatment:  Current therapy for CMC principally revolves around prolonged use of antifungal agents. However, there have also been attempts to ameliorate the underlying immune defect of CMC.  Antifungal Therapy  Immunotherapy Thank you...