This PowerPoint presentation demonstrate a useful review of Oral candidiosis, including its different types, clinical presentations, differential diagnosis, and treatment options.

1. LIBYAN INTERNATIONAL MEDICAL UNIVERSITY
FACULTY OF DENTISTRY
Ziad S. Abdul MajidOral Medicine
ORAL CANDIDIOSIS
: A REVIEW

2. Outlines
 Overview.
 Microbiologic point of view.
 Factors which increase susceptibility of oral
candidosis.
 Classification of oral candidosis.
 Differential diagnosis.
 Investigations.
 Management.
 Clinical case presentation.
 References.

3. Overview
 Oral Candidiasis is one of the common fungal
infection affecting the oral mucosa.
 These lesions are caused by the yeast Candida
albicans.

4. Candida albicans
 Are found in small numbers in the
Commensal flora (mouth, gastrointestinal tract
,vagina ,skin).
 30% to 50% people carry this organism.
 Rate of carriage increases with age of the
patient.
 Candida albicans are recovered from 60% of
dentate patients mouth over the age of 60
years.

5. Virulent factors of Candida albicans
 The ability to adhere to host tissue and
prostheses and form biofilms.
 The potential to switch ( e.g. rough to smooth
colony formation ) and modify the surface
antigens.
 The ability to form hyphae that helps in tissue
invasion.
 Extracellular phospholipase ,proteninase and
haemolysin production which break down
physical defence barriers of the host .

6.  There are three general factors which helps
the Candida albicans infection to develop in
the patient’s body.
 They are:
1. Immune status of the patient.
2. Oral mucosal environment.
3. Strain of Candida albicans.

7. Main factors which increase susceptibility of oral candidiasis are:
( Samaranayake et al 2007).
 Chronic local irritants.
 Ill fitting appliance.
 Inadequate care of appliance.
 Disturbed oral ecology or marked changes in
the oral flora by antibiotics , corticosteroids,
xerostomia.
 Dietary factors.
 Immunological and endocrine disorders ( e.g.
Diabetes mellitus)

8. Cont.
 Malignant and chronic diseases.
 Severe blood dyscrasias.
 Radiation to the head and neck.
 Abnormal nutrition.
 Age ( e.g. very young or very old )
 Hospitalization.
 Oral epithelial dysplasia.
 Heavy smoking.

9. Classification Of Oral
Candidosis
OLD Classification

10.  Acute candidosis:
i. Thrush.
ii. Acute antibiotic stomatitis.
 Chronic candidosis:
i. Denture-induced stomatitis.
ii. Chronic hyperplastic candidosis.
iii. Chronic mucocutaneous candidosis.
iv. Erythematous candidosis.
 Angular stomatitis (common to all types of oral
candidosis)
OLD Classification :

11. Newest Classification
(Greenberg et al. 2008)

12. Primary oral candidosis
 Acute forms:
• Pseudomembranous
• Erythematous
 Chronic forms:
• Hyperplasic (nodular or plaque-like)
• Erythematous
• Pseudomembranous
 Candida-associated lesions:
• Denture stomatitis
• Angular cheilosis
• Median rhomboid glossitis
 Keratinized primary lesions with candidal super
infection:
• Leukoplakia
• Lichen planus
• Lupus erythematosus

13. Secondary oral candidosis
 Oral manifestations of systemic
mucocutaneous candidosis:
• Thymic aplasia.
• Candidosis endocrinopathy syndrome.
• Acquired immune deficiency syndrome (AIDS).

14. Pseudomembranous candidosis
 Thrush forms soft, friable, and creamy colored
plaques on the mucosa .
 The distinctive feature is that they can be
wiped off, to expose an erythematous
mucosa.
 The plaques consist of necrotic material,
desquamated epithelial cells, fibrin and fungal
hyphae.
 Their extent varies from isolated small flecks to
widespread confluent plaque.

15. Cont.
 This form of candidosis is most common in
immunocompromised individuals, in
extremes of age, poorly controlled diabetes
mellitus, HIV infections.
 patients taking corticosteroids, anti-
proliferative or psychotropic medications and
patients on long-term broad-spectrum
antibiotic therapy.
 Smear shows many Gram-positive hyphae.
 Histology shows hyphae invading superficial
epithelium with proliferative and inflammatory
response.

16. Cont.
 Rarely, persistent thrush is an early
sign of chronic mucocutaneous
candidosis such as candida-
endocrinopathy syndrome.

17. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

18. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

19. Acute antibiotic stomatitis
 This can follow 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.
 Generalised 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.

20. Erythematous candidosis
 This term applies to patchy red mucosal
macules due to C. albicans infection in HIV-
positive patients.
 Favoured sites, in order of frequency, are the
hard palate, dorsum of the tongue and soft
palate.

21. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

22. Hyperplasic candidosis
 presents as a well demarcated, slightly elevated,
adherent white lesion of the oral mucosa ranging
from small translucent lesions to large, dense
opaque plaques.
 It may present as one of two variants: as an
isolated, adherent white plaque (homogeneous
form) Or as multiple white nodules on an
erythematous background (nodular or speckled
form).
 The most common location of such lesions is the
post-commissural buccal mucosa, and less
frequently the tongue, and the palate posterior to

23.  Recognition of such
lesions is important as
they have been
associated with a higher
degree of dysplasia and
malignancy than
leukoplakia with no
Candidal association.
Cont.
Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

24. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

25. Denture stomatitis
 A well-fitting upper denture or even an orthodontic
plate cuts off the underlying mucosa from the
protective action of saliva.
 Cause lesions manifested as symptomless area of
erythema.
 Similar inflammationis 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.
 Smoking also appears to increase susceptibility
to this infection.

26.  In the past, denture-induced stomatitis was
ascribed to 'allergy' to denture base material but
there is no foundation for this fancy.
 Methylmethacrylate monomer is mildly sensitising
but even the rare individuals sensitised to it can
wear the polymerised material without any
reaction.
Cont.

27. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

28. Angular cheilosis
 Caused by leakage of candida infected saliva at the
angles of the mouth. It can be seen in infantile
thrush, denture wearers or in association with
chronic hyperplastic candidosis.
 Clinically, there is mild inflammation at the angles
of the mouth; In elderly patients with denture-
induced stomatitis, inflammation frequently extends
along folds of the facial skin extending from the
angles of the mouth .
 These folds have frequently but unjustifiably been
ascribed to 'closed bite', but in fact, are due to
sagging of the facial tissues with age.

29. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

30. Median rhomboid glossitis
 characterized by a symmetrical, erythematous,
elliptical or rhomboid-like area located on the
posterior dorsal surface of the tongue just
anterior to the circumvallate papillae
 This area represents atrophy of the filiform
papillae.
 Histologically fungal hyphae are seen invading
the superficial layers of parakeratotic epithelium
with hyperplastic rete pegs.
 Fungiform and filiform papillae are usually
absent.

31. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

32. Differential
Diagnosis

33. Differential diagnosis based on clinical presentation
(Neville et al)
White lesions
(can be wiped off)
• Erythematous
(atrophic)
candidosis
•Traumatic erythema
• Erythema migrans
• Thermal erythema
• Erythroplakia
• Erosive lichen
planus
• Mouthwash or
toothpaste
reaction
• Chronic
hyperplastic
candidosis
• Leukoplakia
•Tobacco keratosis
• Lichen planus
• Pseudomembranous
candidosis
• Materia alba
• Coated tongue
• Thermal or chemical
injury
• Mouthwash or
toothpaste
reaction
White lesions
(cannot be wiped
off)
Red lesions

34. INVESTIGATIONS

35. Investigations
 When the clinical diagnosis is unclear,
additional tests, such as exfoliative cytology,
culture, or tissue biopsy, may be useful to
confirm a diagnosis.

36. Laboratory investigations
 Recognition of the pathogen in tissue by
microscopy
 Isolation of the causal fungus in culture
 The use of serological tests
 Detection of the fungal DNA by polymerase
chain reaction (PCR)

37. Gram stain of a surface scraping from a patient with pseudomembranous
candidiasis showing yeast spores and mycelia among epithelial cells
Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

38. Sabouraud agar culture demonstrating growth of C.
albicans
Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell

39. PAS-stained biopsy demonstrating candidal hyphae and
pseudomycelia

40. Management Strategies

41. Treatment goals
 The goals of treatment are to identify and
eliminate possible contributing factors,
prevent systemic dissemination, and
eliminate any associated discomfort.
 Pharmacological treatment should be
tailored to the individual patient, based on his
or her current health status and the clinical
presentation and severity of infection.

42. Management
 Confirm diagnosis with smear (most types) or
biopsy (chronic hyperplastic candidosis)
unless presentation is typical.
 Check history for predisposing causes which
may require treatment.
 If candidosis is recurrent or not responsive to
treatment, test for anemia, folate and vitamin
B12 deficiency and perform diabetes
investigations.

43. If a Denture is worn:
1. Cease night-time wear.
2. Check denture hygiene.
3. Soak denture overnight in
antifungal ,(dilute hypochlorite,
chlorhexidine mouthwash) or,
less effective, apply miconazole
gel to denture fit surface while
worn.

44.  If a Steroid inhaler is used, check it is being
used correctly, preferably with a spacer.
 Advise to rinse mouth out after use.
Cont.

45. Pharmacological treatment
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Cl
N
N
ClH

46. Pharmacological treatment
Immunosuppression
or
otherwise resistant
to
treatment
Angular
stomatitis
Chronic
hyperplastic
form
Generalised acute or
chronicType
fluconazole
50 mg/day for 7-14
days
Or
or itraconazole
(100 mg/day
for 14 days)
Or
Ketokenezole
Miconazole
gel 24 mg/ml
QDS 10-14 d
Or
or fusidic
acid cream
Miconazole
gel
24 mg/ml.
Apply QDS
Or
For recurrent
infection in
white patches
fluconazole
may be
required
simultaneously
Nystatin 100 000
units QDS for 7-10
days as suspension
Or
Amphotericin 10 mg
QDS as lozenges or
suspension 10-14
days.
Drug of
choice
&
regime

47. References
1. Essentials of oral pathology and oral medicine ; R.A.Cawson , E.W Odell
2. Neville, Oral and Maxillofacial Pathology, 2nd Ed
3. ORAL CANDIDIASIS: A REVIEW ; YUVRAJ SINGH DANGI1, MURARI LAL
SONI1, KAMTA PRASAD NAMDEO1International Journal of Pharmacy and
Pharmaceutical Sciences 2010
4. Oral candidosis Quintessence Int 2002
5. Oral Candidiasis – A Review ;Prasanna Kumar Rao Scholarly Journal of
Medicine 2012
6. Oral fungal infections: an update for the general practitioner ; CS Farah,* N
Lynch,* MJ McCullough , Australian Dental Journal 2010