Oral Candidal infections

Question 1

What is candidosis and what when does it cause disease?

Answer 1

Candidosis is cause by several species of candida (C. albicans most common) that are normal commensals.

Candida sp. is dimorphic. Carriage is associated with yeast (blastospore) form and only invasive hyphal form causes disease

Change from commensal to pathogenic follows changes in oral environment

Question 2

Predisposing factors to oral candidosis. Why do these factors trigger invasive hyphae

Answer 2

Extremes of age
Immunodeficiency (DM, HIV, chemotherapy)
Immunosuppression 
Anaemia
Antibacterials
Xerostomia
Denture wearing
Smoking

• These factors influence adhesion of the yeast to epithelial cells which trigger development of hyphae after the innate immune response has been activated

Question 3

Classification of candidosis

Answer 3

• in reality these diseases merge into one another and can coexist

Acute candidosis

• thrush
• acute antibiotic stomatitis

Chronic candidosis

• denture-induced stomatitis
• chronic hyperplastic candidosis
• chronic mucocutaneous candidosis
• erythematous candidosis

Angular stomatitis

Question 4

Clinical features and treatment of thrush (acute pseudomembranous candidosis)

Answer 4

• Common in extremes of age, asthma inhaler users and following antibiotic treatment
• Uncomfortable, bad taste or burning
• Creamy soft patches readily wiped off to expose erythematous mucosa
• Hyphae invading superficial epithelium
• Manage predisposing factors and responds to topical antifungals

Question 5

Clinical features of angular cheilitis

Management of angular cheilitis

Answer 5

• Infection at commissure of the lips, typically caused by leakage of candida-infected saliva
• Seen with thrush in infants, in denture wearers, in association with chronic hyperplastic candidosis or alone
• Mild inflammation at the angels of the mouth with cracking
• Morphology of the lips contribute (esp in elderly due to loss of elasticity and sagging)
• targeted at treating the intraoral reservoir of candida using local measures and antifungals
• miconazole gel is first line tx for the commissures
• high proportion of pts with anaemia as predisposing factor so check this
• edentulous with loss of lip support - attempt to correct the vertical dimension or thicken labial flange

Question 6

What are the types of erythematous candiosis and when is the term used?

Answer 6

Term for any candida infection that produces red mucosa

acute antibiotic stomatitis
median rhomboid glossitis
denture stomatitis
erythematous candidosis (if candida infection produces red area but does not fit the description of a specific condition)

Question 7

Clinical features, cause and treatment of acute antibiotic stomatitis?

Answer 7

• whole mucosa is red and sore, tongue worst affected and appears smooth having lost its filiform papillae
• cause: overuse or topical oral use of ABs that suppresses the normal oral flora that competes with candida
• tx: withdraw ABs and accelerate recovery with topical antifungal tx

Question 8

Clinical features, cause and treatment of median rhomboid glossitis?

Answer 8

• Low level infection that permanently damages the mucosa and its ability to form papillae and appears red
• flat diamond shape pink/red patch in the midline of the dorsum
• Predisposing factor is if part of the tongue rests against the soft palate trapping saliva
• tx: reassurance (antifungals do not resolve lesion)

Question 9

Clinical features, cause and treatment of Denture stomatitis?

Answer 9

• Mucosal erythema sharply restricted to area covered by denture frequently associated with angular cheilitis
• Cause: well fitting upper denture (enclosed mucosa cut off from protective saliva), night wear of denture
• Tx: diagnosis by smear, coat fitting surface with miconazole gel

Question 10

Clinical features, cause and treatment of Chronic hyperplastic candidosis (candidal leukoplakia)?

Answer 10

• Adults, most are smokers
• Usual sites: buccal mucosa, dorsum of tongue
• Plaque is of variable thickness often rough
• Can develop a erythematous background or speckling resembling speckled leukoplakia (high risk to develp into carcinoma
• Cause: Chronic low level candidosis induces a localised zone of epithelial keratosis
• But candida can infect keratotic lesions of true leukoplakia to produce the same clinical appearance and hard to tell the two apart

-Tx: antifungal miconazole gel +/- systemic fluconazole, if plaque still remains following intervention it may be leukoplakia with superimposed candida and requires follow up as potentially malignant

Question 11

Cause of and when to recognise Chronic mucocutaneous candidosis?

Give example of the syndrome

Answer 11

e. g. autoimmune polyendocrine syndrome I
- syndromes are rare
- recognise them when chronic candida infection present with very florid (red) involvement, proves resistent to tx or presents in childhood
- Seem to be caused by immunodeficiency