Oral Mycotic Infections Candidiasis 1 /endodontic courses

INDIAN DENTAL ACADEMY
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At the end of the lecture the student should
describe
 Growth and nutrition of Candida
 Morphogenesis
 Predisposing factors
 Immunopathogenesis of Candidiasis
 Distribution in oral cavity
 Classification

 Caused by yeast like fungus
 Candida belongs to the Class Deuteromycetes. They
are classified among Fungi imperfectii due to their
inability to form a sexual stage.
 Candidal species of medical importance - C. albicans,
C. tropicalis, C.glabrata, C. krusei, C.parapsillosis,
C.dubliniensis, C. pseudotropicalis.
 C. albicans exist in two forms (dimorphism) yeast like
and hyphal form

 Candida have the ability to form
Pseudohyphae. Individual member can be
distinguished
1. by colonial morphology &
2. their patterns of carbohydrate assimilation
and fermentation,
3. serological tests.

 Grow on a defined medium consisting of a
source of salts, carbon, and nitrogen
(ammonium salts) and phosphate.
 Temperature range from 20-40 C.
 pH range from 2-8 (optimal being 5.1- 6.9)
 Growth is enhanced by – vitamins & amino
acids.

 Under different environmental conditions
C.albicans exhibits a number of different
morphological forms
1. Budding yeast cells ---- Temperature < 33°C
2. Pseudohyphae ----- Temperature > 33°C
and near neutral pH
3. True hyphae
4. Chlamydospores

 Transformation from yeast to mycelial form
requires
 Correct nutrient state….
 Presence of an inducer – N –
acetylglucosamine,
Proline, Serum
 Elevated temperature > 33°C and near neutral
pH

a. Mycelial & Pseudohyphal forms b. Yeast cells
c. Germ Tube formation

This may be helpful for the organism to
 Invade & proliferate in extremely different
body environments.
 Elude immune system by alterations in
surface antigenicity.
 Escape antifungal treatment

 Most common oral fungal infection with variety of
clinical manifestation
 Component of normal oral microflora
 Three general factors determine clinical evidence
1. The immune status of host
2. The oral mucosal environment
3. The strain of C. albicans

 Infection may range from mild superficial
mucosal involvement to fatal, disseminated
disease in severely immunocompromised
patient

 Oral carriage rate varies from 2-71 %
 Infants > Adults> Young Children
 Depending on the method used –
1. Saliva / Mouthwash and imprint culture 41-
47%.
2. Swab method - About 17%
 C. albicans – 47-84%
 C. glabrata & C. tropicalis – 7% each

 Prevalence & concentration varies by
presence /absence of appliance
 Most common - tongue
 Less frequently - Cheeks, floor of the mouth,
angle of mouth
 Dentures – fitting surfaces of upper denture &
palate.

 Acute and chronic diseases like tuberculosis,
diabetics mellitus and anemias,
 Myxedema, hypoparathyroidism and Addison's
disease
 Immunodeficiency like AIDS
 Nutritional deficiency like iron, Vit A and B6
 Prolonged hospitalization for chronic illness and
debilitating diseases

 Prolonged use of antibiotics, corticosteroids and
cytotoxic drugs.
 Radiation therapy
 Malnutrition
 Old age, infancy and in pregnancy
 Alcoholism

Acute
 Acute pseudomembranous oral candidiasis
(thrush)
 Acute atrophic oral candidiasis (antibiotic
sore mouth)
Classification of Candidiasis

Chronic
 Chronic hyperplastic oral candidiasis
 Chronic mucocutaneous candidiasis
1. Chronic familial
2. Chronic localized
3. Chronic diffuse
4. Candidiasis endocrinopathy syndrome
 Chronic atrophic oral candidiasis (denture sore
mouth)

1) Primary oral candidiasis
 Acute forms:- Pseudomembranous and Erythematous
 Chronic forms:- Hyperplastic (Nodular and plaque
like), Erythematous and Pseudomembranous
 Candida associated lesions :- Denture stomatitis,
Angular cheilitis, Median rhomboid glossitis

 Keratinized primary lesions super infected with
Candida :- Leukoplakia, Lichen planus, Lupus
erythematosus.
2) Secondary oral candidiasis
 Oral manifestations of systemic mucocutaneous
candidiasis
 Candidiasis endocrinopathy syndrome

 More common form
 Any age- debilitated or chronically ill
 Soft white elevated plaques on buccal mucosa &
tongue….

 Plaques grossly resemble like milk curds, consist
chiefly of tangled masses of fungal hyphae with
intermingled desquamated epi……
 Can be wiped away leaving normal / erythematous
area.
 Concomitant involvement of oral cavity and esophagus
is common in HIV patients

 Also known as
‘Antibiotic Sore Mouth’;
sequelae to antibiotic
therapy.
 Central papillary
atrophy of tongue and
angular cheilitis)
 Lesions appear red /
erythematous
 Consistently painful

 Oral lesions – Firm,
White persistent
plaques usually on
lips, tongue, and
cheeks.
 May persist for years;
‘leukoplakia’ type of
candidiasis

 Denture sore mouth
 Most common form of oral disease
 A diffuse erythema and edema of the
denture bearing area with angular cheilitis
 Usually asymptomatic except for the
soreness
 Mandibular mucosa is rarely affected

 Characterized by chronic candidial involvement of the
skin, scalp, nails and mucous membrane.
 Pt exhibit varying abnormalities in immune system
 Inherited disorder probably an autosomal recessive
 Occurs early in life usually before the age of 5 years

 Severe form occurring early in life – no
genetic transmission
 Mouth – primary site along with skin
involvement

 Least common & is of late onset ( pts. over
55yrs.)
 Raised, crusty sheets on face, limbs scalp,
shoulders
 Oral lesions – Firm, White persistent plaques

 Genetically transmitted
 Infection of the skin, scalp & mucous memb. in
asso. with hypoadrenalism, hypothyroidism,
hypoparathyroidism or diabetes mellitus
 Oral lesions are seen before the endocrine
manifestations in children.

Clinical type Appearance and
symptoms
Common
sites
Associated factors
and comments
Pseudo-
membranous
Creamy white
plaques,
removable,
burning sensation,
foul taste
BM, Tongue,
Palate
Antibiotic therapy,
immunosupression
Erythemato
us
Red macules,
burning sensation
Post. Hard
palate, buccal
mucosa,
dorsal tongue
Antibiotic therapy,
xerostomia,
immunosupression,
idiopathic
Clinical features

Central
papillary
atrophy
Red, atrophic
mucosal areas,
asymptomatic
Midline post.
Dorsal
tongue
Idiopathic,
immunosupressi
on
Angular
cheilitis
Red, fissured
lesions,
irritated raw
feeling
Angles of
mouth
Idiopathic,
immunosupressi
on, Loss of
vertical
dimensions
Denture
stomatitis
Red
asymptomatic
Confined to
palatal
denture
bearing area
Probalbly not
true infection

Hyperplasti
c (Candidal
leukoplakia)
White plaques
that are not
removable,
asymptomatic
Anterior
buccal
mucosa
Idiopathic,
immunosupression
Muco-
cutaneous
White plaques,
some are
removable red
areas
Tongue
buccal
mucosa
palate
Rare , inherited or
sporadic idiopathic
immune
dysfunction
Endocrine
candidiasis
syndromes
White plaques,
most are non-
removable red
areas
Tongue
buccal
mucosa
palate
Rare , endocrine
disorder develops
after candidiasis.

 The pseudo membranous and erythematous variants
form the most common clinical presentations of
mucosal candidiasis associated with HIV-infection
 Symptoms may include burning pain, altered taste
sensation, and difficulty swallowing liquids and solids

 Immunodeficiency – T- helper cells predisposes to
secondary infections (fungi being fairly common)
 C. albicans serotype B is prevalent.
 The pseudomembranous form can be easily
diagnosed by demonstrating the presence of candidal
yeast and pseudohyphae on wet mounts or stained
smears of material obtained by swabbing the lesions

 Confirmed by isolation of Candida species on
culture.
 In the erythematous form, the sparse presence
of Candida at the mucosal surface frequently
requires a biopsy and periodic acid-Schiff
staining to establish a formal diagnosis.

 Candidiasis can occur at any time during the course
of HIV infection
 Oral burdens of C. albicans are augmented in HIV-
infected patients even prior to the first episode of
Candidiasis and the intensity of carriage increases
significantly in the progression from asymptomatic
Candida carrier to an episode of Candidiasis

 Pseudomembranous form of OPC and esophageal
candidiasis increases dramatically in advanced HIV
disease associated with CD4+ cell counts of
<200/mm3
, while erythematous candidiasis and
angular cheilitis are less strongly associated with
late disease

 Non-homogenous leukoplakias are often invaded by
yeasts - Candida albicans
 N-nitroso-benzylmethylamine (NBMA) is a compound
able to induce carcinoma of the esophagus and the
oral cavity in the rat

 The catalytic potential to produce NBMA from
the precursors N-benzyl-methylamine and
nitrite showed the highest nitrosation potential
of C. albicans strains.

 Microscopically in either in exfoliative cytologic
preparation or in tissue sections of biopsy
 The PAS staining method the organism are easily
identified by the bright magenta color
 For diagnosis of candidiasis

 Hyphae or pseudohyphae (elongated yeast cells), 2um
in diameter, vary in length and may show branching,
accompanied by variable no. of yeast, Squamous
epithelial cells, inflammatory cells.
 10% to 20% potassium hydroxide preparation may be
used
 The histological pattern of oral candidiasis may vary
slightly

 Increased thickness of parakeratin with elongated
epithelial retepegs
 Typically chronic inflammatory cell infiltrate in the
CT and
 small collection of neutrophils in parakeratin layer
or superficial spinous layer
 The candidal hyphae are embedded in the
parakeratin layer

Isolation of yeast from oral samples
 Smear
 Swab
 Imprint culture
 Impression culture
 Salivary culture
 Oral rinse culture
 Primary culture media

 Identification of candidiasis species
 Morphological tests
 Direct microscopy
 water mount /wet film
 KOH technique
 Germ tube test
 Chlamydospore formation

 Physiological tests – carbon and nitrogen assimilation
 carbohydrate fermentation

 Rapid commercial systems
 Other methods – strain differentiation
 Serotyping
 Biotyping
 Resistogram typing
 Biopsy

Sabouraud’s agar CHROM agar
incubate 48h,37°C
Germ tube test
-ve +ve
C. albicans
Carbohydrate
assimilation
incubate 24-72h,37°C
C. species
identified
48h,37°C incubate
Colony appearance
Green- C. albicans
Dark green- C. dubliniensis
Blue – C. tropicalis
Pale & flat- C.krusei
Molecular methods
Epidemiologic studies
Culture Direct smear

 Oral therapy is convenient and very effective as first-
line treatment. (azole antifungal drugs are not
recommended for use during pregnancy.)
 Fluconazole 100 mg OD for 7-14 days
 Alternative topical therapy (less expensive, safe for
use during pregnancy, and effective for mild to
moderate disease).
 Clotrimazole troches dissolved in the
mouth 5 times/day for 2 weeks

 Nystatin oral suspension 5 mL "swish and
swallow" 4 times daily for 2 weeks
 Other alternatives include the following:
 Itraconazole oral solution 200 mg once
daily for 7-14 days
 Itraconazole capsules and ketoconazole
200 mg once daily for 7-14 days (less
effective)

• Patients should maintain good oral hygiene by brushing teeth
after each meal.
• A soft toothbrush should be used to avoid mouth trauma.
• Advise patients to rinse the mouth of all food before using
lozenges or liquid medications.
• Tell patients to avoid foods or liquids that are very hot in
temperature or very spicy.

 Patients who have candidiasis under a denture or
partial denture should remove the prosthesis before
using topical agents such as clotrimazole or nystatin.
At bedtime, the prosthesis should be placed in a
chlorhexidine solution until reinserting it into the
mouth.
 Pregnant women should avoid azole drugs (eg,
fluconazole, itraconazole, voriconazole) because they
can cause skeletal and craniofacial abnormalities in
infants

 The cultural characteristics of C. albicans,
various subtypes of Candida species
 Classification of various lesions caused by
Candida.
 Clinical features of Candidiasis.

 Text Book of Microbiology Ananthanarayan R 7th
Edition
 Text book of oral pathology Shafer's, 5 & 6th
edition
 Oral Candiosis, Samarnayak L P Ist
edition
 Color Atlas of Oral Diseases Cawson, R. 2nd
edition
 Oral and Maxillofacial Pathology Neville, Brad W. 2nd
 Lucas’s Pathology Of Tumor’s of the Oral Tissues
 Cawson, R.A., Bennie,W. H 5th
edition

Oral Mycotic Infections Candidiasis 1 /endodontic courses

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