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ORAL MEDICINE > orofacial fungal infections > Flashcards

orofacial fungal infections Flashcards

1
Q

what % of healthy individuals is candida species found in?

A

35-55%

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2
Q

what other fungi species can be found in healthy individuals that rarely cause disease?

A

saccharomyces
geotrichum
cryptococcus

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3
Q

are candida harmless?

A

usually harmless but under certain conditions may switch to pathogenic form and cause disease

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4
Q

name some e.g of candida species

A

C albicans (most common/principal)
C glabrata
C tropicalis
C kefyr
C krusei
(all pathogenic)

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5
Q

name some e.g of other rare fungal species

A

Aspergillus spp
Cryptococcus spp
Geotrichum spp
Saccharomyces spp

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6
Q

when does candida cause problems ?

A

when it overgrows due to e.g dry mouth, antibiotics, immunosuppressed pts

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7
Q

what word describes candida existing in diff shapes/morphology

A

pleomorphic

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8
Q

what’s the main form of C albicans?

A

ovoid

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9
Q

what filamentous forms does C albicans change to due to environmental changes?

A

hyphae
pseudohyphae (elongated, not true hyphae)

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10
Q

name e.g of environmental changes that cause a morphological change in C albicans

A

decrease in pH
increase in temp
increase in CO2
increase in nutrients e.g glucose

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11
Q

what are ovoid cells well suited to do in immunosuppressed pts?

A

haematogenous spread

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12
Q

what are hyphal cells adapted to do and how?

A

invasion, colonisation and avoiding macrophages
due to elongated form

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13
Q

what is tongue coating caused by and how is it managed?

A

-build up of food + bacteria deposits in filiform papillae on dorsum of tongue
-manage by increasing fluid intake & roughage in diet + gentle tongue brushing

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14
Q

where is candida mainly found?

A

dorsum of tongue

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15
Q

in who does candida increase?

A

pregnant women
smokers
poorly controlled diabetics
denture wearers

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16
Q

list general predisposing factors of pathogenic C albicans

A

broad spectrum antibiotics
corticosteroids
cytotoxics (chemo)
poorly controlled diabetes
xerostomia
nutritional deficiencies
immunosuppression

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17
Q

list local predisposing factors of pathogenic C albicans

A

trauma e.g ill fitted dentures
tobacco smoking
reduced salivary flow
carb rich diet

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18
Q

how do broad spectrum antibiotics affect candida levels

A

cause change in oral microflora which control candida levels by competing for dietary substrates and epithelial cell adhesion

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19
Q

how do xerogenic agents affect candida levels

A

cause reduction in salivary flushing and antifungal salivary components

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20
Q

why is oral candidosis sometimes the first presentation of immunodeficiency?

A

bc cell mediated immunity & humoral immunity are important in prevention + elimination of fungal infections

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21
Q

what is a predisposing haematological factor of candidosis & how?

A

blood type o -> increased H antigen which is a receptor for C albicans

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22
Q

what is a predisposing dietary factor of candidosis & how?

A

-malnutrition/deficiencies (iron, vit b12, c) -> reduced host defences + mucosal integrity allowing hyphal invasion and infection
-CHO rich diet -> can increase adherence of candida to epithelilal cells

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23
Q

is candidosis usually a local or systemic infection?

A

local

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24
Q

symptoms of oral candidosis

A

altered taste
oral dryness
dysphagia (if oesophageal infection occurs)

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25
Q

what are the acute forms of candidosis

A

pseudomembranous (‘thrush”)
erythematous/atrophic

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26
Q

what are the chronic forms of candidosis

A

chronic hyperplastic candidosis (CHC)
erythematous (denture stomatitis)

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27
Q

what are the secondary forms of candidosis

A

median rhomboid glossitis
angular cheilitis
chronic mucocutaneous candidosis

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28
Q

clinical features of thrush (pseudomembranous candidosis)

A

detachable creamy-white/yellowish patches on oral mucosal surfaces
wipes off & has erythematous base
asymptomatic lesions

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29
Q

who is thrush classically found in?

A

immunocompromised (HIV, extremes of age, DM)

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30
Q

what is thrush frequently associated with?

A

angular cheilitis
oesophageal candidosis (in HIV)

31
Q

management of thrush

A

improve OH
smoking cessation
investigate & treat systemic issues (e.g immunosuppression, DM, anaemia)
live active yogurt
topical agents -> chlorhexidine m/w, anti-fungal agents (nystatin, miconazole gel)

32
Q

clinical features of erythematous candidosis

A

painful erythematous patches
commonly on dorsum of tongue & palate
associated with chronic use of broad spectrum antibiotics (‘antibiotic sore mouth’) & corticosteroids
found in HIV

33
Q

clinical features of CHC (chronic hyperplastic candidosis)

A

white/erythematous raised lesions that don’t rub off
usually on buccal mucosa bilaterally towards commissures
may have associated angular cheilitis
may be nodular/speckled -> more prone to malignancy OR white plaque like
generally asymptomatic

34
Q

who is CHC most commonly found in

A

middle-aged male smokers

35
Q

what is CHC a form of

A

chronic hyperkeratosis (in which candida is identified)

36
Q

management of CHC

A

biopsy to recognise if premalignant
check iron/folate/vit b12 levels
remove predisposing factors (smoking, controlled DM)
systemic anti-fungals (oral fluconazole 2-4+ weeks)

37
Q

clinical features of chronic erythematous candidosis ( denture stomatitis)

A

marked erythema of palatal mucosa with sharply defined margins
if relief area present, may result in underlying spongy granular change
asymptomatic (except angular cheilitis)
rarely involves lower arch

38
Q

cause of denture stomatitis

A

denture fit excludes saliva from supporting mucosa allowing candida to overgrow
inadequate OH/ denture hygiene
poorly fit dentures
affects 65%

39
Q

describe newtons classification

A

type 1 - pinpoint hyperaemia (red spots)
type 2 - diffuse erythema limited to denture fit surface
type 3 - nodular appearance of palatal mucosa

40
Q

management of denture stomatitis

A

improve denture hygiene
eliminate tissue trauma (tissue conditioners)
miconazole gel applied to denture fit surface (caution as absorbed systemically & can interact with drugs e.g warfarin)
if lack of resolution consider systemic issues

41
Q

clinical features of angular cheilitis

A

symmetrical erythematous fissuring in commissures
decreased vertical dimension with maceration of underlying skin (assoc with saliva pooling)

42
Q

predisposing aetiological factors in angular cheilitis

A

lip morphology
reduced haematinic levels (B12, iron)
malabsorption disorders e.g chrons
immunosuppression
DM
broad spectrum antibiotics
xerostomia

43
Q

management of angular cheilitis

A

correct predisposing factors
correct vertical dimension
improve OH and denture hygiene
treat intraoral candida with topical agents
miconazole gel to corners of mouth
if chronic, trimovate cream

44
Q

who does angular cheilitis mainly affect

A

elderly edentulous with denture stomatitis
people with thrush, CHC

45
Q

clinical features of median rhomboid glossitis

A

localised candidal infection with atrophy of filiform papillae
asymptomatic diamond shaped smooth area anterior to circumvallate papillae

46
Q

what is median rhomboid glossitis strongly associated with

A

smoking
corticosteroid inhalers

47
Q

management of median rhomboid glossitis

A

smoking cessation
address inhaler technique
check for predisposing factors
systemic anti-fungal (fluconazole)

48
Q

aetiology/cause of chronic mucocutaneous candidosis (CMC)

A

impaired cellular immunity to candida

49
Q

what is CMC associated with

A

rare congenital disorders e.g APS-1

50
Q

what is APS-1 (autoimmune polyendocrine syndrome type 1)

A

rare monogenic autosomal recessive disease with varied onset (0-18yrs)
CMC usually first major feature

51
Q

clinical features of CMC in APS-1

A

initially presents as as oral thrush with angular cheilitis
becomes more chronic with atrophy and leukoplakia
painful with acidic/spicy food

52
Q

how is oral candidosis diagnosed

A

usually clinically (with thrush and denture stomatitis)
if possible take microbial sample (to identify, quantify and assess resistance)

53
Q

which candida species are more resistant to some anti-fungal agents

A

C glabrata
C krusei

54
Q

what are 6 diff candidal sampling methods & their adv/disadv

A

1) whole saliva culture
+ gives fungal load
- not suitable in xerostomia

2) concentrated oral rinse
+ gives fungal load
- requires specialised lab

3) sponge imprint culture
+ gives fungal load, site specific
- requires specialised lab

4) swab
+ site specific
- doesn’t give load

5) smear
+ no lengthy culture required
- doesn’t give species

6) biopsy
+ indicated for CHC
- doesn’t give load or species, MOS procedure

55
Q

4 types of anti-fungal agents

A

1) polyenes (nystatin, amphoterecin)
2) azoles (fluconazole, miconazole, ketoconazole)
3) 5-flucytosine
4) echinocandins (caspofungin, micofungin, anidulafungin)

56
Q

MoA (mechanism of action) & administration of polyenes

A

disrupts fungal cell membrane (fungicidal)
topical

57
Q

MoA & adminsitration of azoles

A

inhibition of ergosterol synthesis (fungistatic)
topical/ systemic

58
Q

MoA & adminsitration of 5-flucytosine

A

inhibition of protein & DNA synthesis
systemic

59
Q

MoA & administration of echinocandins

A

inhibition of B1,3 D-glucan synthesis
intravenous

60
Q

therapeutic indications for topical anti-fungal agents

A

superficial infection
denture wearers, AB drug use, diabetics

61
Q

therapeutic indications for systemic anti-fungal agents

A

immunosuppressed
candidal leukoplakia (e.g CHC)

62
Q

MoA of nystatin, dose & adverse effects

A

MoA - prevents fungal membrane ergosterol synthesis
dose - oral suspension 4x day for 1-2 weeks
effects - oral irritation, sensitisation, nausea

63
Q

MoA of amphotericin, dose & adverse effects

A

MoA - binds with fungal membrane ergosterol -> cell death
dose - lozenges 10mg 4x day 10-15 days
effects - mild GI disturbances

64
Q

MoA of azoles

A

inhibit lanosterol demethylase -> no ergosterol synthesis

65
Q

why is there azole resistance

A

overproduction/altered lanosterol demethylase
compensation by other sterol synthesis enzymes

66
Q

2 types of azoles and e.g

A

1) imidazoles (miconazole, ketoconazole, clotrimazole)
2) triazoles (fluconazole, itraconazole, voriconazole, posaconazole)

67
Q

how is miconazole used & dose

A

gel applied to affected area (e.g denture fit surface, dentures can be left in)
has anti-staphylococcal activity
dose - gel 25mg, 4x day for 2 weeks after meals

68
Q

how is ketaconazole used & dose

A

systemic
non-specific (inhibits testosterone & cortisol synthesis)
dose - 200mg 1x for 2 weeks

69
Q

contraindications for ketoconazole

A

not used in in pts with liver disease or alcoholics as hepatotoxic

70
Q

contraindications for fluconazole

A

pregnancy
breast feeding

71
Q

side effects of fluconazole

A

nausea/vomitting
diarrhoea, flatulence
rashes
hepatitis

72
Q

what drugs does fluconazole affect & how?

A

reduces metabolism of several drugs by inhibiting CYP3A
-benzodiazepines
-calcium channel blockers
-ciclosporin
-warfarin

results in increased conc and toxicity

73
Q

which candida species may show decreased susceptibility/frank resistance to fluconazole

A

C glabrata
C dublinensis

74
Q

what has been developed to combat resistant species

A

echinocandins
(C parapsilosis and C guillermondii often resistant)

ORAL MEDICINE (1 decks)

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