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Oral Candidiasis
Oral Candidiasis / Candidosis is the most common oral
fungal infection in man especially in early and later life.  In
the general population, carriage rates have been reported
to range from 20% - 75% without any symptoms.  It is
usually caused by
C.albicans.

Candida is a yeast, which is an obligate organism in
humans and a normal constituent of the digestive and
vaginal tracts.  It generally causes no problems in healthy
people.
Classification

There are a number of different types of oro-pharyngeal candidiasis including
acute pseudomembranous, acute atrophic, chronic hyperplastic, chronic atrophic,
median rhomboid glossitis & angular cheilitis.


Oral Candidiasis Clinical Spectrum

The oral lesions of Candidiasis have a different appearance and occur in several
clinical forms.  A patient can have several different presentations of
Oral Candida
at the same time.  For example,
denture stomatitis at the same time as angular
cheilitis.

Traditionally, these have been based on clinical, mycological, histological,
serological & therapeutic criteria.

This classification divides
Oral Candidiasis into acute and chronic types with further
sub-dvisions.

Acute:

  • Acute Pseudomembranous Oral Candidiasis (Thrush)
  • Acute Atrophic Oral Candidiasis (Erythematous)

Chronic:



Chronic Hyperplastic Candidiasis was further subdivided into 4 groups based on
localisation pattern & endocrine (hormonal) involvement as follows:

1.
Chronic Oral Candidosis (Candidal Leukoplakia)
2.
Candidiasis Endocrinopathy Syndrome
3.
Chronic Localized Mucocutaneous Candidiasis
4. Chronic Diffuse Candidosis


A newer classification categorises Candidiasis into:
Predisposing Factors
Acute Pseudo-Membranous Oral Candidiasis (Thrush)


What is Acute Pseudo-Membranous Oral Candidiasis (Thrush)?

Thrush or acute pseudo-membranous candidosis occurs in 5 per cent of newborn
infants and in 10 per cent of elderly debilitated individuals and is one of the earliest
and sometimes the initial manifestations of AIDS.
What are the signs & symptoms?

Clinically, appears as creamy white or yellowish plaques that are fairly adherent to
oral mucosa.  The lesions vary from small discrete areas to confluent white
patches covering a wide area and the coating is easily rubbed off to leave a red
and slightly bleeding surface.


How is it Diagnosed?

The diagnosis of Thrush is usually clinical & straightforward.  Candida can be
confirmed with by the clinical appearance and by culture of
Candida from the saliva
(using a swab or oral rinse).


What are the causes of Acute Pseudo-Membranous Oral Candidiasis (Thrush)?

Predisposing factors for Thrush include changes in local / systemic oral immunity.  
Thrush is commonly associated with antibiotic or steroid use or xerostomia (dry
mouth).  If these local factors can not be identified, systemic factors must be
suspected.

Thrush is, importantly, “a disease of the diseased”, seen mainly in immuno-
compromised patients
.  This decreased immunity can stem from immuno-
suppressive drugs
, HIV infection, leukæmia or other malignancies.


How is it treated?

Possible predisposing factors should be looked for and if possible, dealt with.

Antifungal medications (both topical & systemic) can be given.


Acute Atrophic Oral Candidiasis / Erythematous Candidiasis (Antibiotic /
Steroid-Induced Stomatitis
)


What is Acute Atrophic Oral Candidiasis (Antibiotic / Steroid-Induced Stomatitis)?


What are the signs & symptoms?

Clinically, there is widespread erythema (redness) and soreness of the oral
mucosa.  This can be concomitant with Thrush.

The tongue is most often affected, although any area of the oral mucous
membrane is susceptible.  Lesions on the
dorsum of the tongue present as
depapillated areas.

Red areas often are seen on the palate of individuals with
HIV infection.

The clinical course may be
acute or chronic.

Patients may complain of tenderness, burning, and
dysphagia, especially if oro-
pharyngeal candidiasis
is associated with œsophageal infections.


How is it Diagnosed?

The diagnosis is usually clinical.  If the ætiology is unclear, culture of Candida from
the saliva (using a swab or oral rinse), a smear for fungal
hyphæ or a blood test
may be helpful management.
Photos of Acute Pseudo-Membranous Oral Candidiasis (Thrush)
Candida species are opportunistic pathogens, which
may cause disease mostly when there are changes in
oral ecology or when the host defenses have been
compromised, hence the epithet “candidosis
is the
disease of the diseased
”.

Overgrowth of
Candida, however, can lead to local
discomfort, altered taste sensation,
dysphagia (pain on
swallowing) from œsophageal overgrowth resulting in
poor nutrition, slow recovery & prolonged hospital stay.  
In immuno-compromised patients, infection can spread
through the bloodstream or upper gastro-intestinal tract
leading to severe infection with significant morbidity and
mortality.

Systemic
candidiasis carries a mortality rate of 71 -
79%.
Images of Candida albicans (hyphae & spores)
Photos of Acute Atrophic Oral Candidiasis / Erythematous Candidiasis
(Antibiotic / Steroid-Induced Stomatitis)
Acute oral candidiasis may complicate steroid / antibiotic therapy particularly with
long-term,
broad spectrum anti-microbials such as tetracycline.

It may arise as a consequence of persistent
acute pseudo-membranous
candidosis
, when pseudo-membranes are shed, may develop de novo, or, in HIV
infection, may precede
pseudo-membranous candidosis.  It is the most common
variant of
candidosis seen in HIV disease.


How is it treated?

Cessation of treatment with the offending antibiotic / steroid medication usually
leads to spontaneous resolution, however this may not be possible and topical
anti-fungals may be necessary prophylactically if the causative therapy is to be
continued.  Systemic anti-fungals may be indicated.

Patients using inhaled steroid prescriptions should be advised to rinse their mouth
after inhalation to ensure speedy resolution of
erythematous candidosis.  
Moreover, routine oral rinsing after inhalation should be suggested as a preventive
measure to all people using inhaled steroid prescriptions.


Chronic Hyperplastic Oral Candidiasis (Candidal Leukoplakia)


Chronic Atrophic Oral Candidiasis (Denture Sore Mouth & Angular Cheilitis)
Useful Articles:

Crit Rev Oral Biol Med 2000.  Oral Candidal Infections & Anti-Mycotics

Dental Update 2000.  Antimycotic Agents in Oral Candidosis. An Overview.
2.Treatment of Oral Candidosis

Dental Update 2001. Oral Candidosis

Postgrad Med J 2002.  Oral Candidiasis

BDJ 2004.  Patterns of Antifungal Prescribing in General Dental Practice

Aust Dent J 2005.  Oral Candidosis & the Therapeutic Use of Antifungal Agents in
Dentistry

Int J Pharmacy & Pharmaceutical Sciences 2010.  Oral Candidiasis - A Review

J Marmara Uni Inst Health Sci 2011.  Oral Candidosis.  Aetiology, Clinical
Manifestations, Diagnosis & Management

Patient.co.uk 2014.  Candidiasis


Useful Websites:

New Zealand Dermatological Society

Patient UK

Emedicine.com

GP Notebook

National Center for Emergency Medicine Informatics

NHS Choices

VirtualMedicalCentre.com

Journal of Oral Microbiology
Treatment of Oral Candidiasis
Last Updated 23rd April2015