OROFACIAL FUNGAL INFECTIONS

Question 1

Predisposing factors of oral candidosis (General & Local)

Answer 1

GENERAL

• broad spectrum antibiotics
• cytotoxics
• corticosteroids (inhaler)
• pregnancy
• xerostomia
• immunosuppresion (HIV/extreme ages)
• uncontrolled diabetes
• Nutritional deficiencies

LOCAL

• ill-fitting prosthesis/denture
• xerostomia
• smoker
• rich carb diet

Question 2

How do drugs effect candida (broad spectrum+ xerogenic agents)

Answer 2

BROAD SPECTRUM
-alter commensal oral microflora
-candida competed with oral microflora for epithelial
cell adhesion and dietary substances

XEROGENIC

• reduce salivary flushing
• reduce antifungal components (lactoferrin, lysozyme, histatines)

Question 3

How does diabetes contribute to Candidosis

Answer 3

• increase in salivary glucose concentration which encourage candida growth and colonization
• reduce salivary flow (flushing+antifungal components)
• lower oral ph (acidic environment which candida favour)

Question 4

Haematological factors and candidosis

Answer 4

• Blood group H antigen is a c.albicans receptor

- Increase H antigen in blood type O

Question 5

What dietary factors are associated with candida?

Answer 5

• Carb rich increase candida adherence

- Deficiencies in: iron,b12,folate, vit c and a

Question 6

Is candida symptomatic? What other oral features is it associated with?

Answer 6

asymptomatic (1% symptomatic)

oral features

• xerostomia
• altered tatse
• dysphagia + odynophagia (poor nutrition intake)
• angular chelitis

Question 7

Oral candidosis classification (3)

Answer 7

ACUTE

• Pseudomembraneous candidosis
• Erythematous candidosis

CHRONIC

• chronic hyperplastic candidosis /leukoplakia candidosis
• erythematous candidosis/ Denture induced candidosis /stomatitis

SECONDARY forms

• median rhomboid glossitis
• angular chelitis
• chronic mucocutaneous candidosis

Question 8

Pseudomembraneous candidosis (features, symptomatic?, associations)

Answer 8

• Detachable white/creamy/yellow confluent patches
• Wipe off leaving erythematous/bleeding base
• asymptomatic
• angular chelitis
• immunosuppresion (HIV diabetes)
• atrophic tongue
• xerostomia
• dysphagia & odynophagia

Question 9

Pseudomembranous candidosis management (investigation AND treatment)

Answer 9

INVESTIGATIONS

• FBC (include blood group)
• Haematinic measurments for nutritional deficiencies
• Blood glucose level for diabetes
• candida smear/swab

MANAGEMENT

• OHI
• 2% CHX mouthwash
• Nystatin suspension 100,000 units QDS for 1 week
• Miconazole oral gel (25mg/ml QDS (4) for 2 weeks after meals)

Question 10

Erythematous candidosis (features, symptomatic?, associations, where most common)

Answer 10

+/- painful erythematous patches
dorsum of tongue and palate
associated with broad spectrum antibiotics & HIV
atrophic and depapillation (erythematous=atrophy)

Question 11

Chronic hyperplastic candidosis (CHC) or candida leukoplakia
(features, symptom?, association, location)

Answer 11

• hyperkeratosis
• bilateral buccal commisieurs extending to angular chelitis
• leukoplakia/erythroleukoplaia raised DOES NOT RUB OFF
• nodular+speckled/homogenous plaque like
• associated with SMOKING
• asymptomatic mainly
• thought that candida can produced nitrosamines increasing risk of dysplasia

-pre-malignant lesion chance of dysplasia (OSCC)

Question 12

CHC management (investigations+treatment)

Answer 12

INVESTIGATIONS
-biopsy malignant risk
-FBC
-Haematinics
-Blood glucose level
-VBA for smoking cessation
-topical antifungals normally ineffective (nystatin suspension, miconazole oral gel)
-Sytemic antifungal fluconazole (2-4 weeks)
50mg QD (1) for 2 weeks or longer

Question 13

Chronic erythematous candidosis/ Denture stomatitis

what is it? link to candida, associations

Answer 13

• erythema under the fits surface of an upper acrylic denture
• lack of saliva in order for the denture to fit and this allows candida overgrowth
• linked to poor OH/poor fit denture
• angular chelitis

Question 14

Newtons classification of denture stomatitis/ chronic erythematous candidosis

Answer 14

TYPE 1- pin point erythema
TYPE 2- Diffuse erythema limited to denture fit surface
TYPE 3- Nodular appearance

Question 15

Denture stomatitis management (treatment)

Answer 15

• improve OHI
• denture hygiene -miltons solution
• tissue conditioner
• Miconazol gel
• nystatin suspension
• 2% CHX mw
• lack of resolution- systemic fluconazole

Question 16

Miconazole drug interaction

Answer 16

warfarin and atrovastatin can be life threatening

Question 17

Angular chelitis aetiological factors

Answer 17

lip morphology
xerostomia
broad spectrum antibiotics
diabetes
immunosuppression
malabsorption (crohns coeliac)
Haematinic deficiencies
candidosis

Question 18

Angular chelitis management

Answer 18

• correct predisposing factors (xerostomia/hematinic deficinecies)
• increase OVD, improve denture hygiene, address deep fissuring
• treat intra oral candida e.g. topical antifungals (nystatin suspension or miconazole oral gel)
• miconazole oral gel @ corners of mouth
• chronic -> trimovate cream

Question 19

Median rhomboid glossitis (what? symtpom?)

Answer 19

• localised candida infection
• atrophy of filiform papilla
• asymptomatic
• diamond shape
• smoking
• corticosteorid inhaler

Question 20

Chronic mucocutaneous candidosis (CMC)

location, aetiology?

Answer 20

• candida infection affecting skin, nails, mucous membrane

- Impaired cellular immunity to Candida

Question 21

Candida sampling methods

Answer 21

• smear (no identifications of species)
• concentrated oral rinse (special lab)
• whole saliva culture (not for xerostomia)
• swab (not quantitative)
• sponge imprint culture (special lab)
• biopsy (CHC - malignant risk)

Question 22

Nystatin (suspension)

Answer 22

polyene antifungal NOT absorbed by the gut

100,000 units QDS for 1 week

Question 23

Miconazole (use, interaction, dose)

Answer 23

oral gel applied on fit surface of denture
applied for angular chelitis
interaction with warfarin and atrovastatin
2.5ml QDS (4) for 2 weeks after meals

Question 24

Fluconazole (what, contraindications, interaction, dose)

Answer 24

systemic antifungal
contraindicated preg+breast feeding
50mg QD (once a day) for 1-2 weeks (longer for CHC)
interactions with: warfarin