BDS10032 Oral Infections: Fungal PDF

BDS10032 Oral infections: Fungal Oral infections: Fungal Aims: • The aim of this lecture is to detail the clinical aspects of fungal infections of the mouth. Objectives: On completion of this lecture, the student should be able to: • Understand the risk factors, clinical presentation, diagnostic p...

BDS10032 Oral infections: Fungal Oral infections: Fungal Aims: • The aim of this lecture is to detail the clinical aspects of fungal infections of the mouth. Objectives: On completion of this lecture, the student should be able to: • Understand the risk factors, clinical presentation, diagnostic process and treatment of spectrum of candida infections of the mouth • Have an awareness of the clinical presentation of systemic mycotic infections of the mouth. Candida albicans • Candida albicans are found normally in 50% of healthy mouth in low concentration. • The normal persistence is due to symbiotic relationship and commensals with lactobacillus acidophilus, which favors the presence of the yeast but its acid production limits its proliferation. • The immune system prevents infection . Oral Candidiasis is defined as: • Multiple disease caused by yeast fungus “Candida”. • It is the most common oral fungal infection in humans. • Other names: candidosis/moniliasis. • Disease-free oral carriage is common. • Perhaps 90 % of healthy people carry the infection but do not have any clinical manifestations. Predisposing factors to candidal infection: I. Systemic Predisposing Factors: 1. 2. 3. 4. 5. 6. 7. 8. Age Drugs Diabetes mellitus Xerostomia Postoperative Leukemia/lymphoma Malnutrition/malabsorption Defective cell-mediated immunity. I. Systemic Predisposing Factors: (1) Age a. New born infant: • Immune system is not active yet. • Salivary gland function is not well developed. • Infection may be acquired during : -Delivery (maternal vaginal candidosis) -Via infected feeding bottle. b. Pregnancy: • Increase of glycogen in vagina & high estrogen, progesterone levels favor candidal growth inducing vaginal candidosis. c. Old ages: • Debilitating diseases • Malnutrition/Malabsorption • Relaxed immune response (2) Drugs: a. Antibiotics: • • • • Topical & systemic antibiotic disturb oral flora. The bacterial count remain at low levels. Candida appears on 5th day & gradually increases. This level remains after stopping antibiotic for 7 days. b. Immunosuppressive drugs (steroids & cytotoxic drugs): • T- lymphocyte production or function is impaired. • Topical steroid affects local immune response. c. Contraceptive pills: • The pills increase estrogen & progesterone levels, inducing vaginal candidosis. d. Anticholinergic drugs: • xerostomia (3) Diabetes mellitus: a. Hyperglycemia & ketoacidosis decreases chemotaxis & phagocytic function of neutrophils. b. Vascular insufficiency decrease the blood flow, reduce oxygen tension affecting chemotaxis of neutrophils. (4) Xerostomia: • Dry mucosa often becomes 2ry infected with candida. • Salivary IgA decreases which acts as first line of protection against adhesion of microorganisms to oral mucosa. (5) Postoperative to any surgical procedure: • Lack of oral hygiene. • Antibiotic administration. • Soft diet/Malnutrition. • Dehydration (xerostomia). (6) Leukemia, lymphoma & Hodgkin’s disease: Are treated with cytotoxic drugs so : • The disease itself affect immune system. • The cytotoxic drug affect immune system. (7) Malnutrition & malabsorption: •Decrease lymphocytes & phagocytic activity. •Iron deficiency depresses immunity. (8) Defective cell-mediated immunity: • Natural immunodeficiency e.g. DiGeorge’s syndrome. • Acquired immunodeficiency e.g. AIDS & immunosuppressive drugs (B) Local Predisposing Factors 1. Repeated trauma of oral soft tissues 2. Excessive smoking. 3. Excessive use of local drugs: a) Antiseptic mouth washes. b) Topical steroid. c) Topical antibiotics. Clinical presentations (classification): Oral candidiasis has several different clinical presentations: 1. 2. 3. 4. 5. 6. 7. Acute pseudomembranous Acute atrophic Chronic atrophic (denture-associated) Chronic hyperplastic Chronic erythematous - median rhomboid glossitis Chronic mucocutaneous – rare Angular stomatitis – common 1) Acute candidosis A. Acute pseudomembranous candidosis: • The most frequently encountered form of candida. Clinical features: -2-3 days old children -immuno-compromised adult -older age Signs: • Raised, soft, white gelatinous or creamy adherent plaques. • Isolated patches or merge to form diffuse white patches depending on the patient’s body resistance. • Pseudomembranous white patches may be surrounded by erythematous band. • Wiping away the pseudomembrane with a cotton tipped applicator, will reveal a tender erythematous, eroded or ulcerated surface. Symptoms: • At any site in the mouth. • A white or yellow soft covering that wipes off to leave an area of redness • usually painless. • May extend to the pharynx & esophagus leading to feeding problem. • Becomes painful as the pseudo-membrane is removed or torn away. • Smear: Many hyphae & neutrophils. •Typically associated with: 1. Immunosuppression 2. People using corticosteroid inhalers 3. Arise secondary to broad spectrum antibiotic •Rarely associated with xerostomia. Treatment : •Topical antifungal drug •Recurrence or resistant to treatment: a) Check for underlying causes. b)Consider HIV infection if thrush extend to pharynx. B. Acute erythematous candidosis 1) Following the administration of broad spectrum antibiotics “antibiotic stomatitis and/or glossitis”. • Oral lesions begin to appear on 5th day. 2) Following systemic corticosteroid therapy. 3) Associated with xerostomia (Generalized redness & soreness of the oral mucosa). 4) Resolves with cessation of causative therapy. Signs:• The oral mucosa is red, atrophic with painful eroded areas. • Angular chielitis may be present. • Tongue; atrophy of papilla (antibiotic glossitis). Treatment : • Topical antifungal drugs. • Stop any causative antibiotic or change to narrower spectrum drug. • Stop steroid therapy. 2) Chronic candidosis (candida associated lesions) A. Denture Sore Mouth • Most common in the upper jaw because:1) The nature of retention of upper denture by negative pressure --- deficient access of (IgA). 2) The intimate contact between upper denture and palatal mucosa bring candida in close contact with the palatal epithelium. 3) Inadequate cleaning of the fitting surface. 4) Wearing of the denture day and night. 5) Delayed hypersensitivity reaction to candida antigen. It is uncommon with lower denture due to: • Nature of retention. • The gum is constantly flushed with saliva which has: a) Mechanical cleansing effect b) Candidal antibodies >>>prevent infection. Signs: a. Generalized inflammation: • The whole oral mucosa of the denture bearing area up to the crest of the ridge. • Diffusely inflamed, brightly erythematous with pebbly to velvety surface & small sized sporadic white flecks. b. Localized inflammation: pin point or localized area of erythema. c. The palatal inflammation may be associated with papillary hyperplasia. d. Angular chielitis in 70 %. Symptoms: • Absent • May be soreness or burning sensation during period of exacerbation. Smear : Scanty hyphae. Treatment: 1. Topical antifungal (amphotericin or nystatin) used while the denture is out. 2. Eradicate candida from denture soak in chlorhexidine or diluted hypochlorite at night. 3. Cease nightwear. 4. Miconazole gel or cream applied to fitting surface of the denture and at the angle of the mouth. 5. ill fitting denture may need relining, patient may be supplied with new denture. B. Angular chielitis: • Soreness, erythema, maceration, ulceration & fissuring affecting the lip commissure. • Inflammation may spread from lip commissure along the skin folds producing conspicuous line of erythema. • Smear: Scanty hyphae. • In other cases, cracking, bleeding or prominent crusting (mixed staphylococcus and candidal infection). • Smear: Staph. & candidal infection. • It can be seen with any type of intraoral candidosis. Etiology of angular chielitis: 1. Typically due to reduced vertical face height due to dentures being old and worn down. 2. In people with severe attrition of the natural dentition 3. Nutritional deficiency e.g. vit. B complex, folate & iron. 4. Occurs with oral dryness or drooling (lip licking). 5. It may be associated with denture sore mouth. Treatment : Topical antifungal 1. Suspension of nystatin or amphotericin intra-orally. 2. Nystatin cream or amphotericin ointment topically applied to the angle of the mouth. 3. If it is mixed infection or if it recur use miconazole gel. N.B. Check for underlying causes if recurrent or resistant to treatment especially anemia. C . Median Rhomboid glossitis (central papillary atrophy) • Smooth pink rhomboid nodular area, devoid of lingual papillae. • Found anterior to the circumvallate papillae. • It is seen in adult, usually symptomless. • Associated with immunosuppression or corticosteroid inhalers, sometimes tobacco use or dry mouth. • More prevalent in diabetics. • Smear: scanty hyphae. Treatment : • • • • Topical antifungal therapy is ineffective. Consider systemic therapy if symptomatic. The pink or lobulated abnormality will remain. Resistance and recurrence likely. N.B. • Not potentially malignant. • The dorsum of the tongue surface is rare site for malignancy (except in tertiary stage of syphilis). 3) Chronic hyperplastic candidosis (Candidal leukoplakia) • Potentially malignant (but evidence is weak) • Thick, white leathery plaque with rough or nodular surface. • Clinically identical to leukoplakia. • Men of middle age & heavy smokers. •Triangular patch on the buccal mucosa adjacent to lip commissure which tapers posteriorly (bilaterally). •Erythematous areas may be located within the white patches (speckled leukoplakia). •Candidal leukoplakia is often associated with angular chielitis. •After elimination of the candida by antifungal drug the hyperplastic epithelium persists (leukoplakia). Differential diagnosis: •Similar clinical features are seen in CMCC. •DD : biopsy using periodic acid Schiff (PAS) Treatment: oBiopsy to exclude or to assess epithelial dysplasia------ excision. oTopical application of Miconazole gel. oSystemic antifungal if extensive. o Resistance & recurrence. Chronic Mucocutaneous Candidosis ( CMCC) • Chronic mucocutaneous candidiasis refers to a group of disorders characterized by recurrent or persistent superficial infections of the skin, mucous membranes & nails with Candida albicans. • The main feature in these heterogeneous disorders is impaired cellmediated immunity against Candida species. • CMCC is a rare group of candidosis characterized by deep candidal invasion of the epidermis & may reach the corium. The development of CMCC is attributed to immune abnormalities: 1- Thymic aplasia . 2- A variety of endocrinopathies 3- Defective cell mediated immunity. Types of Chronic Mucocutaneous candidosis : 1.Familial. 2.Diffuse“candidal granuloma”. 3.Candidosis endocrinopathy syndrome. 4.CMCC of late onset. 5.CMCC associated with: a) Primary immunodeficiency: i. DiGeorge's syndrome ii. Defective neutrophil function : b) HIV infection • Oral mucosa is involved in all cases of CMCC & appear similar to chronic hyperplastic candidosis & affect any part of the oral mucous membrane : a) Hyperplastic mucocutaneous lesions b) Localized granulomas c) Adherent white plaques on affected mm • Smear: Firm scraping shows scanty hyphae. Treatment: CMCC persists & responds poorly to topical treatment with nystatin or amphotericin. It may respond to imidazole antifungal drugs. Once the treatment is discontinued the organism rapidly reappears. Monitor associated treatment. disorder which may require Rare systemic fungal infections of the mouth Aspergillosis v. rare (oral ulceration) Histoplasmosis v. rare (oral ulceration/pigmentation) Blastomycosis rare (Americas mainly) – oral/labial ulceration Cryptococcosis oral/gingival ulceration, on the decrease due to ART Paracoccidiodomucosis S. America (esp Brazil, orofacial ulceration/destruction) Mucormycosis rare, observed in US and Europe (palatal ulceration/destruction Diagnosis of candidosis 1. Case history. 2. Clinical examination of the lesion. 3. Special investigation: a) Bacterial smear : egg shaped budding and hyphae of candida. b) Bacterial culture using Sabouraud’s modified agar the colonies appear white and have bad odor because they ferment sugar. c) High candidal antibody titer in serum & saliva. d) Biopsy for candidal leukoplakia. 4. Resolution by antifungal drugs. Treatment of oral candidosis I. Predisposing factors should be eliminated or corrected: 1. Antibiotics & corticosteroids should be stopped if possible. 2. Poorly fitted dentures should be replaced and oral hygiene improved. 3. Diabetes mellitus should be controlled & search for other systemic diseases. II. Antifungal agents: A) Topical therapy indicated for : A- Mild superficial infection. B- Patient resistance is relatively good. B) Systemic therapy indicated for : A- Deep seated infection. B- Superficial infection that is refractory to topical agent. Acute oral lesions: • Respond rapidly for a period of 7-10 days. • Continue 2 weeks after clinical resolution of the lesion. Chronic oral candidosis: • Response less to antifungal drugs. • Should be maintained 4 weeks at least. Antifungal agents 1) Nystatin. 2) Amphotericin. 3) Imidazole anti-fungal agents: a. Miconazole b. Ketoconzole c. Fluconazole d. Itraconazole 4) Chlorhexidine 0.1 – 0.2 % • Increase fungal cell membrane permeability. • Interfere with candidal adhesions to mucosal cells. • Uses : as prophylactic and as adjunct to other antifungal. 1) Nystatin a)Nystatin suspension held in patients mouth for several minutes (4 times/day). b)Nystatin pastille to be sucked (4 times/day). 2) Amphotericin •Lozenges to be sucked (4 times/day) or 3% ointment to be applied several times a day. •Intravenous administration for deep and systemic candidosis. Mode of action: •Nystatin & Amphotericin act by forming holes in the fungal cell membranes causing cell lysis. 3) Imidazole anti-fungal agents: Effective against superficial, deep and systemic mycosis and include: a- Miconazole: is available as cream and oral gel (Daktarin). b-Ketoconzole: • It is used in resistant candidal infection • Available in 200 mg tablet once daily. • Available also as a cream which is effective in angular stomatitis. • Contraindicated in acute liver disease & pregnancy. • Patient on antacids should take the drug 2 hours after the antacid. c. Fluconazole: • used with caution with anticoagulant/antiepileptic/antidiabetic • The dose is 100 mg /day. d. Itraconazole: 100 mg capsule once/day. • Further reading: • Odell E.W. Cawson’s Essentials of Oral Pathology and Oral Medicine. 9th Edition. Elsevier, 2017 pp 244-254 • Robinson M et al. Soames’ and Southam’s Oral Pathology. 5th edition. Oxford University Press, 2018 pp 32-36 • Scully C. Oral and Maxillofacial Medicine Churchill Livingstone 2008 pp 191-200 Oral infections: Fungal Aims: • The aim of this lecture is to detail the clinical aspects of fungal infections of the mouth. Objectives: On completion of this lecture, the student should be able to: • Understand the risk factors, clinical presentation, diagnostic process and treatment of spectrum of candida infections of the mouth • Have an awareness of the clinical presentation of systemic mycotic infections of the mouth.