Oral Mycotic Infections Candidiasis (Candidosis, Moniliasis, Thrush) /orthodontic courses by Indian dental academy

Oral Mycotic Infections
Candidiasis
(Candidosis, Moniliasis, Thrush)
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Learning Objectives
• At the end of the lecture the student should
describe
• Clinical features of Candidiasis
• Laboratory diagnosis
• Cancerous potential of Candida
• Treatment

Chronic Familial Mucocutaneous
Candidiasis
• Characterized by chronic candidial involvement of the
skin, scalp, nails and mucous membrane.
• Pt exhibit varying abnormalities in immune system
• Inherited disorder probably an autosomal recessive
• Occurs early in life usually before the age of 5 years

Chronic Localized Mucocutaneous
Candidiasis
• Severe form occurring early in life – no genetic
transmission
• Mouth – primary site along with skin
involvement

Chronic Diffuse Mucocutaneous
Candidiasis
• Least common & is of late onset ( pts. over
55yrs.)
• Raised, crusty sheets on face, limbs scalp,
shoulders
• Oral lesions – Firm, White persistent plaques

Candidiasis Endocrinopathy Syndrome
• Genetically transmitted
• Infection of the skin, scalp & mucous memb.
in asso. with hypoadrenalism, hypothyroidism,
hypoparathyroidism or diabetes mellitus
• Oral lesions are seen before the endocrine
manifestations in children.

Clinical type Appearance and
symptoms
Common
sites
Associated factors
and comments
Pseudo-
membranous
Creamy white
plaques,
removable,
burning sensation,
foul taste
BM, Tongue,
Palate
Antibiotic therapy,
immunosupression
Erythemato
us
Red macules,
burning sensation
Post. Hard
palate, buccal
mucosa,
dorsal tongue
Antibiotic therapy,
xerostomia,
immunosupression,
idiopathic
Clinical features

Central
papillary
atrophy
Red, atrophic
mucosal areas,
asymptomatic
Midline post.
Dorsal
tongue
Idiopathic,
immunosupressi
on
Angular
cheilitis
Red, fissured
lesions,
irritated raw
feeling
Angles of
mouth
Idiopathic,
immunosupressi
on, Loss of
vertical
dimensions
Denture
stomatitis
Red
asymptomatic
Confined to
palatal
denture
bearing area
Probalbly not
true infection

Hyperplasti
c (Candidal
leukoplakia)
White plaques
that are not
removable,
asymptomatic
Anterior
buccal
mucosa
Idiopathic,
immunosupression
Muco-
cutaneous
White plaques,
some are
removable red
areas
Tongue
buccal
mucosa
palate
Rare , inherited or
sporadic idiopathic
immune
dysfunction
Endocrine
candidiasis
syndromes
White plaques,
most are non-
removable red
areas
Tongue
buccal
mucosa
palate
Rare , endocrine
disorder develops
after candidiasis.

AIDS related Oral Candidosis
• The pseudo membranous and erythematous variants
form the most common clinical presentations of
mucosal candidiasis associated with HIV-infection
• Symptoms may include burning pain, altered taste
sensation, and difficulty swallowing liquids and solids

• Immunodeficiency – T- helper cells predisposes to
secondary infections (fungi being fairly common)
• C. albicans serotype B is prevalent.
• The pseudomembranous form can be easily
diagnosed by demonstrating the presence of
candidal yeast and pseudohyphae on wet mounts or
stained smears of material obtained by swabbing the
lesions

• Confirmed by isolation of Candida species on
culture.
• In the erythematous form, the sparse presence
of Candida at the mucosal surface frequently
requires a biopsy and periodic acid-Schiff staining
to establish a formal diagnosis.

• Candidiasis can occur at any time during the course of
HIV infection
• Oral burdens of C. albicans are augmented in HIV-
infected patients even prior to the first episode of
Candidiasis and the intensity of carriage increases
significantly in the progression from asymptomatic
Candida carrier to an episode of Candidiasis

• Pseudomembranous form of OPC and esophageal
candidiasis increases dramatically in advanced HIV
disease associated with CD4+ cell counts of
<200/mm3
, while erythematous candidiasis and
angular cheilitis are less strongly associated with late
disease

Cancerous potential of Candida
• Non-homogenous leukoplakias are often invaded by
yeasts - Candida albicans
• N-nitroso-benzylmethylamine (NBMA) is a compound
able to induce carcinoma of the esophagus and the
oral cavity in the rat

• The catalytic potential to produce NBMA from
the precursors N-benzyl-methylamine and
nitrite showed the highest nitrosation
potential of C. albicans strains.

Histopathological features
• Microscopically in either in exfoliative cytologic
preparation or in tissue sections of biopsy
• The PAS staining method the organism are easily
identified by the bright magenta color
• For diagnosis of candidiasis

• Hyphae or pseudohyphae (elongated yeast cells),
2um in diameter, vary in length and may show
branching, accompanied by variable no. of yeast,
Squamous epithelial cells, inflammatory cells.
• 10% to 20% potassium hydroxide preparation may
be used
• The histological pattern of oral candidiasis may vary
slightly

• Increased thickness of parakeratin with elongated
epithelial retepegs
• Typically chronic inflammatory cell infiltrate in the CT
and
• small collection of neutrophils in parakeratin layer or
superficial spinous layer
• The candidal hyphae are embedded in the
parakeratin layer

Lab diagnosis
Isolation of yeast from oral samples
• Smear
• Swab
• Imprint culture
• Impression culture
• Salivary culture
• Oral rinse culture
• Primary culture media

• Identification of candidiasis species
• Morphological tests
• Direct microscopy
• water mount /wet film
• KOH technique
• Germ tube test
• Chlamydospore formation

• Physiological tests – carbon and nitrogen assimilation
• carbohydrate fermentation
•
• Rapid commercial systems
• Other methods – strain differentiation
• Serotyping
• Biotyping
• Resistogram typing
• Biopsy

Clinical specimen
Sabouraud’s agar CHROM agar
incubate 48h,37°C
Germ tube test
-ve +ve
C. albicans
Carbohydrate
assimilation
incubate 24-72h,37°C
C. species
identified
48h,37°C incubate
Colony appearance
Green- C. albicans
Dark green- C. dubliniensis
Blue – C. tropicalis
Pale & flat- C.krusei
Molecular methods
Epidemiologic studies
Culture Direct smear

Treatment
• Oral therapy is convenient and very effective as first-
line treatment. (azole antifungal drugs are not
recommended for use during pregnancy.)
– Fluconazole 100 mg OD for 7-14 days
• Alternative topical therapy (less expensive, safe for use
during pregnancy, and effective for mild to moderate
disease).
– Clotrimazole troches dissolved in the mouth 5
times/day for 2 weeks

– Nystatin oral suspension 5 mL "swish and swallow"
4 times daily for 2 weeks
• Other alternatives include the following:
– Itraconazole oral solution 200 mg once daily for 7-
14 days
– Itraconazole capsules and ketoconazole 200 mg
once daily for 7-14 days (less effective)

Patient Education
• Patients should maintain good oral hygiene by brushing teeth
after each meal.
• A soft toothbrush should be used to avoid mouth trauma.
• Advise patients to rinse the mouth of all food before using
lozenges or liquid medications.
• Tell patients to avoid foods or liquids that are very hot in
temperature or very spicy.

• Patients who have candidiasis under a denture or
partial denture should remove the prosthesis before
using topical agents such as clotrimazole or nystatin.
At bedtime, the prosthesis should be placed in a
chlorhexidine solution until reinserting it into the
mouth.
• Pregnant women should avoid azole drugs (eg,
fluconazole, itraconazole, voriconazole) because they
can cause skeletal and craniofacial abnormalities in
infants

Summary
• The clinical appearance of various forms of
Candidial infection.
• Laboratory diagnosis of Candidiasis.

BIBLIOGRAPHY
 Text Book of Microbiology Ananthanarayan R 7th
Edition
 Text book of oral pathology Shafer's, 5 & 6th
edition
 Oral Candiosis, Samarnayak L P Ist
edition
 Color Atlas of Oral Diseases Cawson, R. 2nd
edition
 Oral and Maxillofacial Pathology Neville, Brad W. 2nd
 Lucas’s Pathology Of Tumor’s of the Oral Tissues
 Cawson, R. A., Bennie, W. H 5th
edition

Oral Mycotic Infections Candidiasis (Candidosis, Moniliasis, Thrush) /orthodontic courses by Indian dental academy

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