BDS IV Oral Candidosis PDF

# BDS IV ## Oral Candidosis - Prof. Mohamed Al Ismaili BDS, MSc., FDSRCPS, FFDRCSI, FCGDent - Head of Oral Surgery - Oman Dental College # Learning Objectives: - Classification of oral candidal infections - Briefly discuss the anti fungal medications available to GDPs and specialists, indication...

# BDS IV ## Oral Candidosis - Prof. Mohamed Al Ismaili BDS, MSc., FDSRCPS, FFDRCSI, FCGDent - Head of Oral Surgery - Oman Dental College # Learning Objectives: - Classification of oral candidal infections - Briefly discuss the anti fungal medications available to GDPs and specialists, indications, contraindications and drawbacks. - Give referral criteria. # Candida: A yeast like fungus commonly found in the oral cavity. ## *Candida albicans:* - Most commonly cultured and associated with disease. - Normal commensal. - Disease by opportunistic overgrowth. # Opportunistic Mycosis: - Some fungi are commensal (mucosal flora of mouth, gut, vagina etc.). - Usually growth is balanced by other microorganisms (lactobacilli). - A problem in situations of compromised immune responses (AIDS, antibiotics, chemotherapy, radiation, alcoholism, etc.). # Predisposing Factors: "Disease of the diseased" - Immunodeficiency (DM, AIDS) or immunosuppression (including steroid inhalers). - Anemia. - Broad spectrum antibiotics. - Xerostomia - cuz saliva have antimicrobial. - Denture wearing - pt don't remove denture at night/don't clean denture. Thrush is more common in smokers. - Smoking # Classification: ## Acute: - Acute pseudo-membranous candidosis (Thrush). - can be removed - leaving red area. - Acute antibiotic stomatitis. - whole mouth appears red. ## Chronic: - Denture induced stomatitis (denture sore mouth) - Chronic hyperplastic candidosis - this occurs in skin + very rare. - Chronic mucocutaneous candidosis - Erythematous candidosis # Acute Pseudomembranous Candidosis (Thrush): - Friable creamy patches that can be easily scrapped off, exposing an erythematous mucosa especially in asthmatic pt. - Often involves oropharynx (also known as angular cheilitis). - May be associated with angular stomatitis. - Affects infants, elderly and immunocompromised. - Neonatal thrush results from immaturity of the immune system and infection from birth canal. - Smear swab for microbiology. # Thrush: - Smear shows many Gram positive hyphae. - Histology shows hyphae invading superficial epithelium with proliferative and inflammatory response. Neutrophils # Thrush: Management - Remove the cause. - Control of any local cause e.g stop topical antibiotic. - Nystatin / Amphotericin lozenges are antifungal drugs. - Failure to respond indicates immunodeficiency. - Manage systemic cause - anemia + HIV. - Systemic fluconazole (100mg OD X 2 weeks). # Acute antibiotic stomatitis: - Suppression of normal flora by overuse or topical use of antibiotics - Generalised erythematous and sore oral mucosa. - Thrush may be present. - Resolution by withdrawal of the antibiotic or accelerated by topical antifungal. # Angular Stomatitis: - Characteristic sign of candidosis. - Crusted cracked lesions at angles of the mouth. - Leakage of infected saliva at the angles of the mouth. - In association with thrush, denture wearers and chronic hyperplastic candidosis. - Iron deficiency anemia. - Co-infection with Staph. aureus and B-haemolytic streptococci. - Treatment of intra oral candidal infection and topical fusidic acid cream. - against Staph. aureus # Denture induced stomatitis: - Deprivation of the underlying mucosa from salivary protective action. - Traumatic occlusion. - Asymptomatic area of erythema. - May be associated with angular stomatitis. - More common in smokers. - Give them denture hygiene. - Put in hypochlorite. # Denture induced stomatitis: Pathology - Gram stained smear - candidal hyphae, yeast forms. - Histology - acanthosis, chronic inflammation. - no need biopsy? cuz we know the cause. # Denture induced stomatitis: Management - Denture hygiene. - Stop night time wear, remove occlusal trauma. - Soaking the denture overnight in 0.1% hypochlorite or chlorhexidine 0.2%. - Miconazole gel on the denture fitting surface TDS. - Failure to respond ?anaemia - treat underlying cause, systemic fluconazole. # Erythematous candidosis: - Patchy red mucosal macules due to Candida albicans associated with low CD4 cell count as in HIV positive patients. - Hard palate, dorsum of tongue and soft palate. - affect attached of gum - Linear gingival erythema - in desquamous gingivitis = will involve margin/papilla usually in AIDS/AIY. - Treatment with itraconazole. # Chronic hyperplastic candidosis: - can't be removed by scrapping. - White folded plaques behind the angles. - Smokers, poor denture hygiene. - Hyphae invasion of the parakeratin layer. # Median Rhomboid Glossitis: - Rhomboid shaped, erythematous patch on the midline dorsal tongue. - Symptomless. - Epithelial hyperplasia with neutrophils in the parakeratin layer. # Antifungal Drugs: - systemic/topical. - only topical. *Polyenes (Amphotericin, Nystatin) - work on cell mem. Selectively bind to ergosterol in fungal cell membrane, altering membrane fluidity and producing pores and osmotic cell death. - Much less binding to cholesterol. - gel = you will commonly prescribe for denture. *Azoles (Ketoconazole, Miconazole, Fluconazole, Itraconazole). Selectively block ergosterol synthesis by inhibiting demethylation of lanosterol. Fungal P450 enzyme much more sensitive than mammalian counterpart. # Antifungal Drugs ## Polyenes: - Amphotericin B - Given IV, (poor oral absorption) and topical. - Active against most systemic fungi. - Not well tolerated (chills, headaches, nausea). - Pronounced renal toxicity. - Nystatin - Only for topical application. # Antifungal Drugs ## Azoles: - inhibit the synthesis of ergosterol. - Fungistatic. - Active against systemic fungi and dermatophytes. - Resistance due to altered 14-demethylase. ## Two groups: - Imidazoles - Triazoles # Antifungal Drugs ## Imidazoles - Ketoconazole - Miconazole - Fluconazole - Iltraconazole ## Imidazoles - Miconazole - Used topical and p.o. (intestinal fungal infections). - Fluconazole (Diflucan®) - Used i.v. and p.o. - 50 mcg. - Cap 50mcg OD x 7 days for 2 weeks in candidal leukoplakia. - Reaches high CSF concentrations. - 90% excreted unchanged. - Used against Candidosis, Coccoidosis (meningitis). - Well tolerated. - Miconazole and Fluconazole (Diflucan®) interact with warfarin (enhance) and with statins (myopathy). - anti cholesterol drugs. ## Imidazoles - Ketoconazole - Tinea, candidiasis, blastomycosis, coccidioidomycosis. - Also for dandruff (Nizoral®). - First oral -azole (mostly replaced by fluconazole and itraconazole). - Absorption best at low pH (antacids interfere !). - Does not enter CNS well. - Itraconazole (Sporanox ®) - Used i.v. and p.o.(p.o. poor absorption). - Absorption increased by acids (Orange juice, Coke!). - Absorption decreased by antacids. - Does not reach CSF. - Very broad spectrum. # Poll This is an image of a QR code.