Infectious White Lesions - 8th Lecture

White & Red lesions LECTURE OUTLINE Identify infectious oral white lesions. LECTURE ILOs Knowledge the causes of oral candidiasis. Differentiate between different forms of oral candidiasis White lesions:  Hereditary  Reactive \ inflammatory  Infectious  Idiopathic leukopla...

White & Red lesions LECTURE OUTLINE Identify infectious oral white lesions. LECTURE ILOs Knowledge the causes of oral candidiasis. Differentiate between different forms of oral candidiasis White lesions:  Hereditary  Reactive \ inflammatory  Infectious  Idiopathic leukoplakia  Erythroplakia  Lichen planus  Lupus erythematosus  Miscellaneous Oral Hairy Leukoplakia: Corrugated white keratotic lesion Usually occurs on the lateral or ventral surfaces of the tongue In patients with severe immunodeficiency. The most common disease associated with oral hairy leukoplakia is HIV infection. Epstein-Barr virus (EBV) is the causative agent Histopathology: Hyperparakeratosis with an irregular surface, Acanthosis with superficial edema, Koilocytic cells (virally affected "balloon" cells) in the spinous layer. The characteristic microscopic feature is the presence of homogeneous viral nuclear inclusions with a residual rim of normal chromatin. Demonstrating the presence of EBV through in situ hybridization, electron microscopy, or Treatment and Prognosis: The condition usually disappears when antiviral medications such as acyclovir are used in the treatment of the HIV infection. Oral Candidosis Oral candidosis is the most common fungal infection that frequently occurs in patients debilitated by other diseases or conditions. No candidosis happens without a cause; so oral candidosis has been branded as ” a disease of the diseased”. Because Candida are normal oral inhabitants, thrush and other forms of oral candidiasis may be classified as specific endogenous infections. Important predisposing factors for oral candidosis Immunodeficiency (e.g. diabetes mellitus or AIDS) or immunosuppression (including steroid inhalers, cancer chemotherapy, and radiotherapy). Poor oral hygiene Pregnancy Anaemia Suppression of the normal oral flora by antibacterial drugs Xerostomia Haematologic malignancies Spectrum of oral candidosis: Angular stomatitis (common to all types of oral candidosis). Acute Pseudomembranous Candidosis (Thrush) Clinical Features: Painless, soft, friable, and creamy plaques on the mucosa. Can be easily wiped off, to expose an erythematous mucosa or shallow ulceration. Their extent varies from isolated small flecks to widespread confluent plaques. Angular stomatitis is frequently associated as it is with any form of intra-oral candidosis. Pathology A Gram-stained smear shows large masses of tangled hyphae, detached epithelial cells and leucocytes. Biopsy shows hyperplastic epithelium infiltrated by inflammatory edema and cells, predominantly neutrophils. Staining with periodic acid Schiff(PAS) shows many candidal hyphae growing down through the epithelial cells to the junction of the plaque with the spinous cell layer. Management Control of any local cause such as topical antibiotic treatment. Nystatin or amphotericin lozenges (topical antifungals) should allow the oral microflora to return to normal. Failure of response to topical antifungals suggests immune deficiency. In immunodeficient patients as in HIV infection, candidosis may respond to fluoconazole or itraconazole. Acute Antibiotic Stomatitis: Overuse or topical oral use of antibiotics, especially tetracycline, suppressing normal competing oral flora. Clinically, the whole mucosa is red and sore. Flecks of thrush may be present. Resolution may follow withdrawal of the antibiotic but is accelerated by topical antifungal treatment.  Generalized candidal erythema which is clinically similar, can also be a consequence of xerostomia which promotes candidal infection. It is a typical complication of Sjogren's syndrome. Nystatin suspension or miconazole gel held in the mouth is usually effective. Denture-induced Stomatitis: Asymptomatic erythema sharply limited to the area of mucosa occluded by a well-fitting upper denture or even an orthodontic plate. Similar inflammation is not seen under the more mobile lower denture which allows a relatively free flow of saliva beneath it. Angular stomatitis is frequently associated and may form the chief complaint. Pathology: Gram-stained smears show candidal hyphae and some yeast forms which have proliferated in the interface between denture base and mucosa. Histologically, there is typically mild acanthosis with prominent blood vessels superficially and a mild chronic inflammatory infiltrate. The inflammation is probably a response to enzymes such as phospholipases produced by the fungus Treatment: Denture cleansing.Cleansers can be divided into groups according to their primary components: alkaline peroxides, hypochlorites, acids, disinfectants, and enzymes. Yeast lytic enzymes and proteolytic enzymes are the most effective against the infection. Denture soak solution containing benzoic acid completely eradicates C albicans from the denture surface as it is taken up into the acrylic resin and eliminates the organism from the internal surface of the  A protease-containing denture soak also effectively removes denture plaque, especially when combined with brushing. An oral rinse containing 0.12% chlorhexidine gluconate results in complete elimination of the presence of C albicans on the acrylic resin surface of the denture and in reduction of palatal inflammation. Diet: High-sucrose diets should be avoided. Median Rhomboid Glossitis : Erythematous patches of atrophic papillae located in the central area of the dorsum of the tongue are considered a form of chronic atrophic candidiasis. Angular Stomatitis: Angular stomatitis is typically caused by leakage of Candida- infected saliva at the angles of the mouth. It can be seen in infantile thrush ,in denture wearers or in association with chronic hyperplastic candidosis. It is a characteristic sign of candidal infection. Erythematous Candidosis: This term applies to red mucosal macules due to Candida albicans infection in HIV –positive patients. Favoured sites: are the hard palate, dorsum of the tongue and soft palate. Treatment with intraconazole is usually effective. Candidal leukoplakia (ch. Hyperplastic): Firm white leathery plaques Cheek ,lip ,tongue ,palate Invasion of candida deeper in mucosa leads to proliferative response of host tissue. Candidal leukoplakia  The differentiation of candidal leukoplakia from other forms of leukoplakia is based on finding periodic acid-Schiff (PAS)- positive hyphae in leukoplakic lesions. Chronic Mucocutaneous Candidiasis: Persistent infection with Candida usually occurs as a result of a defect in cell-mediated immunity or may be associated with iron deficiency. Hyperplastic mucocutaneous lesions, localized granulomas, and adherent white plaques on affected mucous membranes are the prominent lesions that identify chronic mucocutaneous candidiasis (CMC). Two categories of CMC have been described: (1) Syndrome-associated CMC (further categorized as either familial or chronic). (2) Localized and diffuse CMC. Candidiasis endocrinopathy syndrome (CES) A rare autosomal recessive disorder characterized by an onset of CMC during infancy or early childhood, associated with the appearance of hypoparathyroidism, hypo- adrenocorticism and other endocrine anomalies Patients develop persistent oral candidiasis and hyperplastic infections of the nail folds at an Chronic candidiasis associated with thymoma The other syndrome-associated form , which appears with other autoimmune abnormalities such as myasthenia gravis. Localized and diffuse CMC Localized CMC is a variant associated with chronic oral candidiasis and lesions of the skin and nails. The diffuse variant is characterized by randomly occurring cases of severe mucocutaneous candidiasis with widespread skin involvement and development of Candida granulomas. Management : Both oral and cutaneous lesions of CMC can be controlled by the continuous use of systemic antifungal drugs. Once treatment is discontinued, the lesions rapidly reappear. Mangment: Oral candidosis is a treatable disease, and the prognosis is usually positive in the majority of patients. A thorough medical history and appropriate workup are crucial for the successful treatment of patients with oral candidosis. The of developing oral candidosis can be reduced by : 1- the elimination of risk factors and maintenance of efficient oral hygiene. Mechanical means to remove heavy candidal plaques from oral lesions is important and can promote antifungal action and speed healing 2-Maintenance of good oral and denture hygiene is crucial. It is important to remove dentures overnight, use denture cleanser, or make a new denture if an ill-fitting denture with stomatitis exists. 3-Rinsing the mouth after use of an inhaled steroid is helpful to prevent oral candidiasis. 4-Glucose promotes yeast growth, and a high-carbohydrate diet enhances its adherence to oral epithelial cells. Limiting their consumption is helpful in the control of oral Candida colonization and infection. 5-Removal of heavy candidal plaques or biofilm from oral lesions by mechanical means can improve antifungal action and speed healing. 6-Nystatin tablets are significantly superior to nystatin oral suspension in treating oral candidosis. Swallowing nystatin tablets rather than sucking or dissolving them in the mouth is ineffective to treat oral candidosis. 7-The duration of antifungal treatment should be sufficient or prolonged for at least four weeks to achieve a more permanent mycological cure. 8-Underlying predisposing factors should be identified and treated simultaneously as well as monitored regularly. 9-The final eradication of oral candidosis is by host defense system. Antifungal Drugs: These medications include clotrimazole, miconazole, or nystatin ,amphotericin B. should be prescribed for 7 to 14 days for mild to moderate cases. Imidazole derivatives (clotrimazole, miconazole) are available for topical use (cream, oral gel).  Systemic therapy includes the use of any one of these three: ketoconazole, itraconazole, and fluconazole. If patient does not get better after taking fluconazole, healthcare providers may prescribe a different antifungal nystatin and amphotericin B or Fluconazole and amphotericin B may be used intravenously for the treatment of the resistant lesions of CMC and systemic candidiasis.