Fungal Infections of Oral Mucosa

1. FUNGAL INFECTIONS OF THE
ORAL MUCOSA
Dr. HADI MUNIB
Oral and Maxillofacial Surgery Resident

2. OUTLINE
 Predisposing factors for Candidal Infections
 Laboratory Investigations for Oral Candidosis Diagnosis
 Clinical Classification of Oral Candidosis
 Pseudomembranous Candidosis
 Erythematous Candidosis
 Hyperplastic Candidosis
 Candida-Associated, Denture-Induced Stomatitis, Angular Cheilitis and Median Rhomboid Glossitis
 Chronic Candidosis Syndrome
 Antifungals used in the treatment of Oral Candidosis
 References

3. TROUSSEAU: “DISEASE OF THE DISEASED”

4.  Fungi that frequently form part of the commensal flora of the human body.
 Swabs taken from the skin, gut, vagina, or mouth of an apparently healthy individual all may
show the presence of Candida species
 The oral carriage rate of oral Candidal species is about 40% of the normal population.
 Candida Albicans.
Introduction

5.  Large yeast-like cells (blastospores) that occasionally elongate to form germ tubes (pseudo-
hyphae). In the inactive state the yeast form is predominant.
 Proteases and extracellular proteins may be produced by the micro-organisms and that these
can induce skin lesions
Introduction

7. Predisposing Factors for Oral Candidosis

8. Fungal Infection
Denture
Wearer
Metabolic
Disorder
Smoker

9. Laboratory Investigations for Oral Candidosis
 Swab; moistened with sterile saline, wiped along the surface of the lesion.
 Smear
 Oral Rinse; with a phosphate-buffered saline solution, will determine the presence of
Candida species and a quantitative assessment of the Candidal count.
 Biopsy; Chronic Hyperplastic Candidosis
 Hematological tests; including a full blood count, estimations of serum ferritin, vitamin
B12, folate (and red cell folate), and a blood glucose tests.

10. Clinical Classification of Oral Candidosis
 Old Classification
 Acute: Pseudomembranous and Atrophic
 Chronic: Atrophic and Hyperplastic

11. Clinical Classification of Oral Candidosis

12. Laboratory Investigations for Oral Candidosis

13. Pseudomembranous Candidosis
 Soft, friable and creamy coloured plaques on the mucosa.
 Pseudo membrane can be wiped away and inflammation underneath it.
 Smear: Periodic Acid-Schiff (PAS) and Swab
 Posterior Pharyngeal Wall: Can be FATAL
 Treatment:
1. Identify cause and eliminate it
2. Antifungal treatment
3. Symptomatic treatment

14. Pseudomembranous Candidosis

15. Acute Erythematous Candidosis
 The mucosa involved is red and painful (The only variant in which pain and discomfort are
marked).
 The epithelium is thin and atrophic with Candidal hyphae embedded superficially in the
epithelium.
 This form is common in patients with AIDS as well as patients undergoing prolonged antibiotic
or steroid therapy.
 Management:
 Topical Antifungal Therapy is usually effective
 If it’s due to Antibiotic course, the lesions will disappear after discontinuation of the drug.

16. Acute Erythematous Candidosis

17. Chronic Hyperplastic Candidosis
 Candidal Leukoplakia
 Neoplasia transformation?
 Raised, Irregular Fixed white patch at the commissures of the mouth. [Palate and
Tongue]
 Can be ‘speckled’ or nodular in appearance.
 Management: Biopsy is needed to confirm diagnosis
1. Eradication of Predisposing factors
2. Antifungal Therapy; Topical and Systemic
3. Long term Follow-up

18. Risk factors: Male, Smoker and Denture
Wearer
Chronic Hyperplastic Candidosis

19.  Chronic Erythematous Candidosis - Misnomer
 Most Common form
 Redness of the mucosa covered by the appliance often with a sharply defined edge
 If a relief area is present on the denture, there may be a corresponding area of spongy
‘granular looking’ tissue.
Candida-Associated – Denture Induced
Stomatitis

20. Newton’s Classification

22. Management of Denture-Induced Stomatitis
 Swabs
 Tissue Trauma: Correction of Denture fitting surface
 Infection: Antifungal cream on the fitting surface – Miconazole.

23. Angular Cheilitis
 Candida-associated lesion.
 Erythema and cracking at the angles of the mouth.

27. Median Rhomboid Glossitis
 Candida-associated lesion.
 Presents as an area of depapillation on the midline of the dorsum of the tongue,
immediately in front of the circumvallate papillae.
 The lesion is classically ‘rhomboid-shaped’— hence the name.
 Its surface may be red, white, or yellow in appearance.
 Patients who present with this lesion should undertake hematological tests
 Long-term therapy with topical antifungal agents - nystatin pastilles - may be effective
in reducing the size of the lesion.

29. Chronic mucocutaneous Candidosis syndromes
 Candidosis of the oral cavity, the skin, and other structures such as the fingernails may
occur, with or without association with other generalized disease processes.
 Oral lesions in CMC may be initially thrush-like, but eventually resemble lesions of chronic
hyperplastic Candidosis.
 The skin lesions may include widespread and disfiguring lesions of the face and scalp.
 Granulomatous lesions of the lips may also occur.

30. Management of CMC
 Difficult to treat and in many cases reduction, but not eradication.
 Predisposing factors should be eliminated
 Treatment is with long-term systemic antifungal therapy such as fluconazole and may
need to be prescribed at doses higher than the normal therapeutic range.
 Regular monitoring of liver function is essential

32. Antifungals used in the treatment of Oral
Candidiasis
 Forms: Lozenges, pastilles, creams, Tablets and suspensions
 Nystatin and amphotericin B, Relatively free of side-effects when used locally but
have poor compliance from patients.
 The systemically acting azoles, itraconazole, fluconazole, and ketoconazole, are
mainly used in systemic Candidal infections in the Immunocompromised.

34. REFERENCES
 Tyldesley's Oral Medicine; Chapter 4: Infections of the oral mucosa and Gingivae
 Cawson’s Essentials; Chapter 12: Infections of the oral mucosa

35. THANK YOU