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ORAL CANDIDIASIS
Risk factors. Clinical forms. Diagnostic and
Treatment
ORAL CANDIDIASIS
OUTLINE
Etiology
Pathogenesis
Diagnosis
Classification
Therapy
Clinical characteristics
Prognosis
ORAL CANDIDIASIS
INTRODUCTION
ORAL CANDIDIASIS
SOURCE
http://www.helpyourautisticchildblog.com/category/candida/
ORAL CANDIDIASIS
ORAL CANDIDIASIS
SPECIES
The causative organism is
usually Candida albicans or
less commonly other
Candida species such as (in
decreasing order of
frequency:
C. tropicalis (1)
C. glabrata (2)
C. parapsilosis (3)
C. krusei (4)
C. dubliniensis (5)
other
ORAL CANDIDIASIS
C. albicans
70-80%
(50%)
Highly virulent
C. glabrata
5-10%
(10-15%)
ORAL CANDIDIASIS
PATHOGENESIS
The host defenses against opportunistic infection of candida species are:
1. The oral epithelium, which acts both as a physical barrier preventing microorganisms from entering the tissues, and is the site of cell mediated immune
reactions.
2. Competition and inhibition interactions between Candida spp and other microorganisms in the mouth.
3. Saliva, which possesses both mechanical cleansing action and immunologic
action, including salivary IgAs antibodies, which aggregate candida organisms and
prevent them adhering to the epithelial surface; and enzymatic components such as
lysozyme, lactoperoxidase and antileukoprotease.
Disruption to any of these local and systemic host defense mechanisms
constitutes a potential susceptibility to oral candidiasis, which rarely occurs
without predisposing factors
ORAL CANDIDIASIS
PATHOGENESIS
Candidal carriage state is not
considered a disease, but
when Candida spp become
pathogenic and invade host
tissues, oral candidiasis can
occur:
The predisposing factors
are:
LOCAL FACTORS
Dentures;
Low of the saliva;
Neglected hygiene etc.
SYSTEMIC FACTORS
Systemic diseases;
HIV/AIDS;
Immunosuppression
Oncological treatment;
Drugs misuse;
Antibiotic treatment etc.
ORAL CANDIDIASIS
ORAL CANDIDIASIS
For example, iron deficiency anemia is thought to cause depressed cellmediated immunity. Some sources state that deficiencies of vitamin A or
pyridoxine are also linked.
There is evidence that a diet high in carbohydrates predisposes to oral
candidiasis.
In vitro and studies show that Candidal growth, adhesion and biofilm
formation is enhanced by the presence of carbohydrates such as glucose,
galactose and sucrose.
ORAL CANDIDIASIS
Smoking
Smoking, especially heavy smoking, is an important predisposing
factor but the reasons for this relationship are unknown. One
hypothesis is that cigarette smoke contains nutritional factors for C.
albicans, or that local epithelial alterations occur that facilitate
colonization of candida species
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Both the quantity and quality of saliva are important oral defenses against
Candida spp.
Decreased salivary flow rate or a change in the composition of saliva,
collectively termed salivary hypofunction or hyposalivation is an important
predisposing factor.
Xerostomia is frequently listed as a cause of candidiasis, but xerostomia can
be subjective or objective, i.e., a symptom present with or without actual
changes in the saliva consistency or flow rate.
ORAL CANDIDIASIS
Denture wearing, and poor denture hygiene, particularly wearing the denture
continually rather than removing them during sleep, is another risk factor, both
for candidal carriage and for oral candidiasis. Dentures provide a relative
acidic, moist and anaerobic environment because the mucosa covered by the
denture is sheltered from oxygen and saliva. Loose, poorly fitting dentures
may also cause minor trauma to the mucosa,which is thought to increase the
permeability of the mucosa and increase the ability of C. albicans to invade
the tissues
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Pathogenesis 2
ORAL CANDIDIASIS
Pathogenesis 3
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Head&Neck radiotherapy
severe xerostomia
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Neutropenia after
chemotherapy
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Erythematous candidiasis usually occurs on the dorsum of the tongue in persons who use
corticosteroid inhalators due to asthma treatment
In individuals who have developed candidiasis secondary to the use of inhaled steroids, rinsing
out the mouth with water after taking the steroid, and using a spacer device to reduce the contact
with the oral mucosa (particularly the dorsal tongue) may be beneficial
ORAL CANDIDIASIS
Imbalance of the oral microbiota. Broad-spectrum antibiotics, which eliminate the competing
bacteria and disrupt the normally balanced ecology of oral micro-organisms..
Lingua nigra villosa and antibiotic sore tongue after oral intake of suspension of Augmentin
ORAL CANDIDIASIS
TONGUE piercing
ORAL CANDIDIASIS
ORAL CANDIDIASIS
C. albicans biofilms may form on the oral piercing surfaces of different materials
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Presence of certain mucosal alterations are sometimes associated with Candida spp
overgrowth, such as fissured tongue (Lingua plicata)
ORAL CANDIDIASIS
Good denture hygiene involves regular cleaning of the dentures, and leaving them out of the mouth
during sleep. This gives the mucosa a chance to recover. In oral candidiasis, the dentures may act as
a reservoir of Candida species
ORAL CANDIDIASIS
SOURCE: Scully, Crispian (2008). Oral and maxillofacial medicine: the basis of
diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. pp. 191199
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Acute Pseudomembranous Candidiasis (Thrush)
is one of the most common type of oral candidiasis, accounting for about 35% of oral
candidiasis cases
slough that can be easily wiped away to reveal erythematous, and sometimes minimally
bleeding mucosa beneath. These areas of pseudomembrane are sometimes described
as "curdled milk". The white material is made up of debris, fibrin, and desquamated
epithelium that has been invaded by yeast cells and hyphae that invade to the depth of
the stratum spinosum.
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Acute Pseudomembranous Candidiasis (Thrush)
Pseudomembraneous candidiasis can involve any part of the mouth, but usually it
appears on the tongue, buccal mucosae or palate.
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Acute Pseudomembranous Candidiasis (Thrush)
However, sometimes it can be chronic and intermittent, even lasting for many
years. Chronicity of this subtype generally occurs in immunocompromised
ORAL CANDIDIASIS
White, cheesy, creamy, loose patches that can be easily rubbed off
Underlying mucosa is erythematous and easily bleeds
Disturbed taste sensations (disgeusia)
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Severe xerostomia
Local application of corticosteroids
Immunosuppression e.g. HIV/AIDS
ORAL CANDIDIASIS
SOURCE
Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo
http://doctorspiller.com/candidiasis.htm
SOURCE
DermNetNZ
http://www.dermnetnz.org/fungal/oral-candidiasis.html
Oral candidiasis in an infant. At very young ages, the immune system is yet to develop fully
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Acute erythematous (atrophic) candidiasis
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Acute erythematous (atrophic) candidiasis
The erythematous candidiasis accounts for 60% of oral candidiasis cases. Where it
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Atrophic (Erythematous) Candidiasis
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Atrophic (Erythematous) Candidiasis
Erythematous candidiasis can mimic
geographic tongue. Erythematous
candidiasis usually has a diffuse border
that helps distinguish it from erythroplakia,
which normally has a sharply defined
border.
geographic tongue
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Candida-associated denture induced stomatitis
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Candida-associated denture induced stomatitis
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Candida-associated denture induced stomatitis
The Newton classification divides denture-related stomatitis into three types
based on severity.
Type one may represent an early stage of the condition, whilst type two is
the most common and type three is uncommon.
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Type 3 - Inflammatory nodular/papillary hyperplasia usually on the central hard palate and the
alveolar ridge
ORAL CANDIDIASIS
Type 3 - Inflammatory nodular/papillary hyperplasia usually on the central hard palate and the
alveolar ridge
ORAL CANDIDIASIS
CLINICAL CHARACTERIASTICS
Glossitis rhombica mediana
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Glossitis rhombica mediana
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Glossitis rhombica mediana
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Angular cheilitis
ORAL CANDIDIASIS
Angular cheilitis is generally occurs in elderly people and is associated with denture related
stomatitis.
Sometimes dentures become very worn, or they have been constructed to allow insufficient lower
facial height (occlusal vertical dimension), leading to over-closure of the mouth. This causes
pronouncement of the skin folds at the corners of the mouth, in effect creating an intertriginous
areas where angular cheilitis can develop.
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Chronic Hyperplastic Candidiasis
The most common site of involvement is the commisural region of the buccal mucosa,
usually on both sides of the mouth.
ORAL CANDIDIASIS
CLINICAL CHARACTERISTICS
Chronic Hyperplastic Candidiasis
largely historical synonym for this subtype of candidiasis, rather than a true
leukoplakia. Indeed it can be clinically indistinguishable from true leukoplakia, but
tissue biopsy shows candidal hyphae invading the epithelium.
Some sources use this term to describe leukoplakia lesions that become colonized
secondarily by Candida species, thereby distinguishing it from hyperplastic
candidiasis.
ORAL CANDIDIASIS
Biopsy is conditional
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Esophageal candidiasis
ORAL CANDIDIASIS
Pseudomembranous Candidiasis
SOURCE:
Classification of oral diseases of HIV- associated immune suppression
(ODHIS) Glick M, Abel SN, Flaitz CM, Migliorati CA, Patton LL, Phelan
JA, Reznik DA (ODHIS Workshop Group-USA, Dental Alliance for
AIDS/HIV CARE DAAC)
ORAL CANDIDIASIS
Oesophageal Candidiasis
SOURCE:
Classification of oral diseases of HIV- associated immune suppression
(ODHIS) Glick M, Abel SN, Flaitz CM, Migliorati CA, Patton LL, Phelan
JA, Reznik DA (ODHIS Workshop Group-USA, Dental Alliance for
AIDS/HIV CARE DAAC)
ORAL CANDIDIASIS
Hyperplastic Candidiasis
SOURCE:
Classification of oral
diseases of HIVassociated immune
suppression (ODHIS)
Glick M, Abel SN,
Flaitz CM, Migliorati
CA, Patton LL, Phelan
JA, Reznik DA
(ODHIS Workshop
Group-USA, Dental
Alliance for AIDS/HIV
CARE DAAC)
ORAL CANDIDIASIS
Erythematous Candidiasis
SOURCE:
Classification of oral diseases of HIV- associated immune suppression
(ODHIS) Glick M, Abel SN, Flaitz CM, Migliorati CA, Patton LL, Phelan
JA, Reznik DA (ODHIS Workshop Group-USA, Dental Alliance for
AIDS/HIV CARE DAAC)
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
The diagnosis can typically be made from the clinical appearance alone, but not always.
As candidiasis can be variable in appearance, and present with white, red or combined
white and red lesions, the differential diagnosis can be extensive.
In general Candida spp are grown in the laboratory on solid growth media or in liquid
broths
Special investigations to detect the presence of candida species include oral swabs,
oral rinse or oral smears.
Molecular diagnosis of Candida spp using real-time polymerase chain reaction (RT PCR), Monoclonal Antibody and Rapid Latex Agglutination (RLA)
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Aside from infection and mechanical trauma, inflammatory reactions of the mucosa beneath a
denture can also result from irritation or allergy (allergic contact stomatitis) caused by the
materials in the denture itself (acrylic, cobalt, chromium), or in response to substances within
denture adhesives. Incomplete curing of the acrylic resin may also be an involved factor
ORAL CANDIDIASIS
Candida appears as large, round, white or cream colonies with a yeasty odor
on agar plates at room temperature.
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
BIOCHEMIC IDENTIFICATION
ORAL CANDIDIASIS
SEROLOGICAL TESTS
ELI.H.A Candida
http://www.elitechgroup.com/corporate/products
/market-segment/microbiology/mycology/
ORAL CANDIDIASIS
ORAL CANDIDIASIS
SOURCE
http://www.medadvocates.org/diseases/opportunistic/candidiasis/
ORAL CANDIDIASIS
SOURCE
PCR-based gene targeting in Candida albicans
http://www.nature.com/nprot/journal/v3/n9/fig_tab/nprot.2008.137_F1.html
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
PCR proceeding
Microlab STARlet IVD (Hamilton)
DNA isolation
MagNA Pure 96 (Roche)
Real-Time-PCR
LightCycler 480 II (Roche)
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Treatment of co-existing
systematic diseases
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Fluconazole
50 150mg/daily for 7-14 days
Itraconazole
2x 100 mg/daily for 7-14 days
Posaconazole (Noxafil)
200 mg/first day. 100 mg/daily for the rest 7-14 days.
ORAL CANDIDIASIS
Before treatment
After treatment
ORAL CANDIDIASIS
Before treatment
After treatment
ORAL CANDIDIASIS
Natamycin (10mg)
4-6x/daily for 7-14 days. It is not absorbed in GIT
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Before treatment
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
Treatment of the infection and inflammation of the lesions with topical antifungal medication,
such as clotrimazole, amphotericin B, ketoconazole, or nystatin cream is recommended.
Some antifungal creams are combined with corticosteroids such as hydrocortisoneor
triamcinolone to reduce inflammation, and some antifungals such as miconazole cream also
have some antibacterial action.
ORAL CANDIDIASIS
ORAL CANDIDIASIS
ORAL CANDIDIASIS
PHOTODYNAMIC THERAPY
ORAL CANDIDIASIS
PHOTODYNAMIC THERAPY
Resolution of the lingua villosa nigra associated with Candida after 1 week's treatment with MB-mediated
photodynamic therapy with diode laser (810nm).
ORAL CANDIDIASIS
PROGNOSIS