Balasubramanian M.S. D.L.O.
Oral candidiasis is a very
fungal infection involving the oral cavity mucosa. These infections
are caused by saprophytic fungi belonging to the genus candida. Common
organisms involved in oral candidiasis include:
Among these organism candida
has been implicated as the common causative organism in oral
candidiasis. Candida albicans is dimorphic in nature, capable of
existing in two forms i.e yeast and hyphal forms. The hyphal form is
associated with oral candidiasis. Studies have shown that candida
albicans can exist in the oral cavity as normal commensal.
factors causing oral
In HIV positive patients
with CD 4 count less than 200/microlitre
Patients with xerostomia
– Use of medications in the elderly are the common cause of xerostomia.
Medications known to cause xerostomia include: antidepressants,
diuretics and drugs with anticholinergic effects.
Use of broad spectrum
antibiotics that could alter the normal gut flora.
Use of systemic steroids
Clincially oral candidiasis
as both erythematous / white forms. White forms are otherwise known
as pseudomembranous type / hyperplastic candidiasis.
candidiasis: This is
the commonly seen type of oral candidiasis. It is also known as oral
thrush. It is usually seen as whitish patches resembling curd over
the oral cavity mucosa. When these white plaques are peeled off it
will expose the underlying erythematous mucosa. This type of oral
candidiasis is common in:
patients with HIV)
Patients who have undergone
transplant surgeries and are on antirejection drugs
Erythematous candidiasis: Oral
mucosa in these patients appear erythematous. This type of
candidiasis is commonly seen in patients with xerostomia and in those
who wear prosthetic appliances for long periods of time. Subtypes of
erythematous candidiasis include:
Acute atrophic candidiasis – This
type of oral candidiasis is also known as antibiotic sore mouth,
since it is common in patients taking broad spectrum antibiotics
which could alter the normal gut flora. These patients typically
manifest with erythema of the affected area of oral mucosa with
atrophy of dorsal lingual papillae. The major problem faced by these
patients is excessive burning sensation in the affected area. This
type of candidiasis is seen in patients with iron deficiency anaemia,
vitamin B12 deficiency etc. Some patients sould be long standing
Chronic atrophic candidiasis – This
is also known as denture stomatitis. This type of candidiasis is
commonly seen in patients wearing ill fitting dentures for prolonged
duration, as well as in those who dont remove their dentures even
during night time. These patients usually present with erythema of
mucosa overlying the denture area. This type of oral candidiasis is
common in the palatal region of denture area which is poorly drenched
Newton classified denture
into three clinical types:
Type I – This is
localized inflammation associated with pin point hemorrhages.
Type II – In this type there
diffuse erythema involving either a portion / entire denture bearing
Type III – There is erythema
denture bearing mucosa with papillary hyperplasia.
Fungal cultures from the
surface of denture / from palatal area covered by denture always
reveal candida albicans. The pores over the acrylic surface of
dentures provide perfect environment for growth of candida albicans.
This condition is caused by
combination of candida albicans and bacterial infection. This
condition is caused by candida albicans i and staphylococcal aureus
mixed infections. These patients have fissures / sores along the
angle of the mouth. This condition usually involves both angles of
mouth. This condition is commonly seen in patients using ill fitting
dentures. Ill fitting dentures cause recession of alveolar margins
causing a decrease in the vertical dimension of occlusion leading on
to accumulation of saliva at the angle of the mouth. This prolonged
stasis of saliva at the angle of the mouth causes a favourable
environment for growth of candida albicans. Other conditions causing
angular chelitis include nutritional deficiencies like:
Vitamin B 12
This condition goes by
i.e. Central papillary atrophy. These patients manifest with well
demarcated area of atrophy of the dorsal lingual papillae. This area
appears like a rhomboid. This lesion lies just anterior to the
circumvallate papillae of the tongue. Some of these patients may
have associated lesion over the corresponding portion of the palatal
mucosa where the posterior portion of tongue comes into contact
during oral phase of deglutition. These are known as satellite /
This condition is
candidal infection in more than one location. These patients may
have concurrent denture stomatitis along with angular stomatitis.
This condition also goes by
candida leukoplakia. Lesions in these patients are whitish and well
defined covering large areas of oral mucosa. These whitish patches
cannot be peeled off from the mucosa. These lesions are commonly
seen in the buccal mucosa, palate, and tongue areas. It is nearly
impossible to distinguish this lesion clinically from leukoplakia.
Diagnosis is usually made in retrospect if the patient doent respond
to topical antifungal agents. Ofcourse these patients dont give
history of tobacco use.
These patients have long
involvement of mucosa of oral cavity, skin and nails of hand. This
condition is resistant to topical antifungal agents. These patients
also have associated endocrine abnormalities like:
Classically diagnosis of
candidiosis depends on clinical signs and symptoms.
Other diagnostic adjuncts
Samples can be
obtained from scrappings of wooden tongue blade. The sample is then
smeared on to a glass slide. It can be fixed with alcohol fixative /
allowed to air dry. The slide is then stained with PAS which shows
up the fungal hyphae.
Qualitative assessment of
albicans: This gives an approximate estimate of the probablity of
candida infection. This test is performed by determining the number
of colony forming units of candida albicans present in 1 ml of
unstimulated saliva. The number of colony forming units can be
determined after 72 hours of incubation at 30 degrees centigrade in
the saburaud agar plate. In healthy individuals the count usually is
Improving the hydration
levels of the patient
Antifungal agents -
These agents act by altering DNA / RNA metabolism. They could also
allow intracellular accumulation of peroxide which could prove toxic to
the fungal cell.
Topical antifungal agent:
Clotrimazole lozenges: This
administered as 10 mg losenges to be dissolved in the oral cavity
five times a day for two weeks. It also has a certain degree of anti
Miconazole buccal tablet: 50
to be dissolved in the oral cavity each morning for 2 weeks.
Genitian violet solution:
managing refractory and highly localised lesions.
Systemic antifuncal agents:
Cap. Fluconazole – 50 – 100
T. Ketoconazole – 200 – 400
T. Miconazole – 50 mg qid
T. Itraconazole – 100 mg qid
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