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Oral Maxillofac Surg (2008) 12:67–71

DOI 10.1007/s10006-008-0106-8


Evaluation and treatment of oral candidiasis in HIV/AIDS
patients in Enugu, Nigeria
Chima Oji & F. Chukwuneke

Published online: 12 June 2008
# Springer-Verlag 2008

Abstract Introduction
Introduction Oral candidiasis is one of the common
diseases seen in HIV/AIDS patients. It is rare if CD4+ cell The fungus called Candida causes oral candidiasis. A small
counts are above 500 μl. Outbreaks are more common as quantity of the fungus is present in the mouth, vagina,
the count drops to 100 μl. It may be more difficult to treat digestive tract, and skin. In a healthy individual, commensal
when CD4+ cell counts fall below 50 μl. organisms and the immune system prevent the fungus from
Materials and methods A retrospective review of 112 HIV/ causing disease [14]. However, a damaged and weakened
AIDS patients with lesions in the mouth, head, and neck immune system, as can be seen in patients with HIV/AIDS
seen at the oral and maxillofacial surgery units of two disease, makes it easier for the Candida to grow, cause
public hospitals in eastern Nigeria was carried out between severe discomfort, and increase the morbidity associated
2000 and 2003. The focus was on oral candidiasis patients. with the HIV/AIDS condition [9, 14, 21, 27]. In these high-
Twenty-nine of these patients, made up of 11 males and 18 risk groups, antifungal prophylaxis reduces the incidence
females, had oral candidiasis. To compare the action of two and severity of the infection. For example, improving oral
drugs, namely, nystatin (a topical antifungal drug) and hygiene and maintaining mechanical cleansing by rinsing
ketoconazole (a systemic antifungal drug), we treated 15 of the mouth with normal saline or home-made salt water
the patients with nystatin in the first 2 years and the several times a day may be helpful [12, 18]. Nittayananta
remaining 14 with ketoconazole in the following 2 years. et al. [19] reported that hyposalivation is significantly
Results and discussion Amongst the 15 patients treated associated with the numbers of oral Candida, and xero-
with topical drugs, 7 (46.7%) had complete remission, 2 stomia is commonly associated with late-stage HIV
(13.3%) had partial response, 4 (26.7%) remained stationary, infection. Therefore, rinsing the mouth with normal saline
and 2 (13.3%) died. Out of the 14 cases treated with systemic may help reduce Candida attachment and make patients
drugs, 11 (78.6%) had complete remission, 2 (14.3%) had feel more comfortable with their mouth conditions. These
partial response, and 1 (7.1%) died. practical, inexpensive ways may minimize the development
of Candida infection because the first step of the infection
Keywords Oral candidiasis in HIV/AIDS . Evaluation . is adhesion of Candida to the mucosa [5]. Oral candidiasis
Treatment . Enugu . Nigeria is usually diagnosed by appearance and symptoms [1].
However, scraping the affected site and examining the
specimen under the microscope can equally confirm the
diagnoses [27]. Further laboratory tests are usually per-
formed if the infection does not clear up after drug
treatment. Several Western studies have shown that the
C. Oji (*) : F. Chukwuneke diagnosis of this disease in HIV/AIDS patients can be made
Oral and Maxillofacial Surgery,
on clinical findings alone [1, 4]. Defining the most effective
University of Nigeria Teaching Hospital,
Enugu, Nigeria diagnostic and therapeutic approach to curing oral candidi-
e-mail: asis in HIV/AIDS patients is especially important in

28]. We noted the clinical and laboratory findings and focused our attention on the 29 oral candidiasis patients. and it is usually well-tolerated. 1 Oral candidiasis in a female HIV/AIDS patient of mycostatin mouth rinse. In the first 2 years of the study. eastern Nigeria. and friable mucosa (Figs. both in Enugu. The lesions showed varieties of irregular white plaques. head. and health centers in the catchments areas of these hospitals. Relevant information during history-taking included patients’ sexual habits. Eleven of the patients were males and 18 were females. Treatment in the early part of the twentieth century was with gentian violet. 1 and 2). 2 Oral candidiasis in a male HIV/AIDS patient . All the patients had the same spectrum of disease at the time of presentation. sex. medical practitioners.68 Oral Maxillofac Surg (2008) 12:67–71 Materials and methods We carried out a retrospective study of 112 HIV/AIDS patients with lesions in the mouth. However. which often have limited resources [24]. We chose ketoconazole as the systemic drug of comparison because it is easily available in Nigeria. Several therapeutic regimens have been effective in treating oral candidiasis [13. Fig. The study compared the responses of oral candidiasis patients treated with topical antifungal drug (nystatin) to those treated with systemic antifungal drug (ketoconazole) in the oral and maxillofacial units of two specialist hospitals in Enugu. They. such as staining the oral mucosa. Topical antifungal therapy was recommended as the first line of treatment for uncomplicated oral candidiasis before the advent of the HIV/AIDS scourge. Nigeria. 3). therefore. The aim of this study was to evaluate 29 oral candidiasis cases amongst 112 cases that had HIV/AIDS symptoms in the head and orofacial regions. social class. a polyene antifungal (nystatin) replaced it because of resis- tance and side effects. therefore. Visual observation and photographs (Fig. qualified for the study irrespective of age. These patients received 5 ml of the mouth rinse in between meals. Furthermore. Each patient underwent complete physical examination. 24. These patients were referred to the units by the dental surgeons. sociodemographic data. we treated 15 of these patients with topical antifungal drug (nystatin) in the form Fig. and neck. we could not measure the lesions because they were friable and irregular. We instructed them to developing countries. profession. etc. confluent pseudomembrane. ethnic group. determined the degree of remission. and time interval before presentation. The period of the study was from January 2000 to December 2003 and it took place in the oral and maxillofacial surgery units of Ntasiobi Specialist Hospital and the Annunciation Hospital. it is cheaper than other systemic drugs. onset of symptoms.

Fig. This was because these substances promote the growth of Candida and cause discomforts while eating [21. The most measured the CD4 cell counts regularly and monitored the liver function while the patients were taking these drugs. most of the patients complained of severe discomforts from eating and swallowing of food. 2 (14. Partial remission is when at remission after 2 weeks of commencement of the treatment. least 50% or less than 100% of the symptoms abated. We took photographs to for comparison.3%) had partial remission. before the commencement of treatment in both groups. However. We administered 200 mg to each patient document these stages of remission (Fig. In the following 2 years. seven of the 11 males and six of the 18 females admitted that they had more than one sexual partner. we administered them at least 2 h before 300 and 150 μl while those that did not respond to the patients took antacids or acid-inhibiting medication. 11 (78.6.6%) had complete remission. patients with total remission had meals. 7 (46.7%) had a complete remission (Fig. daily for 2 weeks. Results Out of the 29 patients that had oral candidiasis. All the patients were advised to maintain good oral hygiene by brushing their teeth at least twice a day and gargling with 3% hydrogen peroxide diluted with equal amounts of water after brushing. and 2 (13. To process and analyze the 50% 2 2 0. None of the patients used condoms. none was stationary. 1 after complete remission In the 14 patients treated with systemic antifungal drugs (nizoral tablets = ketoconazole). The Table 1 Test of significance between the two treatment methods acronym CD4 stands for [c(cluster of) d(differentiation Methods of treatment antigen) 4] and is a glycoprotein predominantly found on the surface of helper T cells.076 data that we collected. The age range was 16–70 years with a mean of 24±6.13 0. an antifungal tablet. .038 the test of significance (Table 1). Because ketoconazole tablets need the acidity of the CD4+ between 450 and 300 μl. 27].01 0. Two (13. Of the 15 patients treated with topical nystatin (mycostatin mouth rinse) within the first 2 years. 3). and symptoms disappeared. giving a male-to- female ratio of 1:1. We advised them to avoid acidic.3%) had partial response. They performed this systemic treatment (Table 1). we used the chi-square test (χ2) for Total 9 13 4. 11 (38%) were males and 18 (62%) were females. There were no homosexuals in this study. The patients took the tablets during In both cases treated. We treatment had their CD4+ less than 150 μl. 4 (26. and 1 (7. procedure four times daily for 2 weeks.7%) remained stationary.4. 3 Patient in Fig.1%) died of the disease. 3). cigarettes. or hot foods.941 100% 7 11 3.Oral Maxillofac Surg (2008) 12:67–71 69 We did not observe any adverse reactions. CD4 cell count is a critical Remission Topical (n=15) Systemic (n=14) χ2 p value indicator of AIDS progression that gauges the number of CD4 cells in 1 mm3 of blood.038) among those patients with total remission in favor of around the mouth and swallow it. However. we treated the remaining 14 Complete remission occurred when all the clinical signs patients with nizoral (ketoconazole).3%) died. and sugary and carbonated drinks while the treatment was going on. An analysis of these figures shows statistical significant difference (p= hold the mouth rinse in the mouth for 3 min then swill it 0. alcohol.27 0. spicy. The treatment was Remission in this context means a diminution or continued for a few days after the clinical signs and abatement of clinical signs and symptoms of the disease symptoms had disappeared in those patients who had within the period of the study. partial remission between stomach to dissolve.

For the past decade. risk factors. Arch Oral Biol 25:1–10 taboos in the Nigerian society because they are regarded as 3. inaccessibility of the medication does exist in the develop. likely that none 101 Cambodians with HIV/AIDS. Blignaut E. although Candidiasis is among the most common conditions in a study in Zaire reported a cure rate of less than 10% [20]. Oral candidiasis constitutes systemic antifungal therapy had complete remission [17]. Furthermore. A study carried candidiasis in developing countries is to prevent the out in Uganda by Maurizio et al. the clinical cure rate of nystatin was 52% and that of systemic Discussion fluconazole 87%. 32 (37. Chidzonga MM (2003) HIV/AIDS orofacial lesions in 156 HIV/AIDS patients. strategies systemic antifungal drug (ketoconazole) was more effective to treat oral candidiasis in HIV/AIDS patients in developing than topical antifungal drugs (nystatin). This may account for the Gastroenterol 84:143–146 acquisition and transmission of HIV/AIDS and other 5. and management of HIV-related disease. Greenspan et al. topical nystatin Zimbabwean patients at referral oral and maxillofacial surgical therapy has been considered effective in controlling oral clinics. [11] reported a marked decrease in oral potassium hydroxide preparations and culture of mucosal candidiasis in women who were treated with HAART. 8. Blignaut et al. we conclude from our result that the use of among HIV/AIDS patients exists.7%) out of 15 patients treated with topical especially in developing countries such as Nigeria. study by Pons et al. it is often the treated with topical therapy had complete remission. It is.6%) were males and 53 (62. Oral Dis 91:317–322 candidiasis [16]. 20]. J Oral Pathol Med 31:145–150 of our patients admitted being homosexual. we share the opinion of this study. Consequently. This study is in agree with Bendick et al. Armstrong D (1992) Fungal infections in AIDS patients. 7. but it is hospital: epidemiology. [25] that compared the efficacy of nystatin and oral fluconazole in HIV-positive patients. 10 (27%) out of 37 patients common condition in the general population. Adv Dent Res 19:122–129 radically changed the clinical course of oral candidiasis in 6. [5] that the optimal goal in dealing with oral which gives a male-to-female ratio of 1:1. 7 (46. Ramirez-Amador V. This is antifungal drug (nystatin) had complete remission while 11 in contrast to the situation in the developed world where (78.6. [17] in 1999 showed that occurrence of the lesion by educating patients on how to out of 85 patients with oral candidiasis in HIV/AIDS enhance their immunity. Fraser VJ. uniform in some African countries [7. This is in contrast to our findings.70 Oral Maxillofac Surg (2008) 12:67–71 common side effects were altered taste sensation and that compared fluconazole and nystatin. 22]. the efficacy of nystatin in treating this disease is not well-known. Aldred MJ.67. J Med Vet Mycol 30:19–28 tion medication that can be used as an alternative to 8. 17]. 1. The introduction of systemic antifungal drug therapy has oral lesions. sexually transmitted diseases in the society. seven 4. 11 (38%) were males and 18 (62%) females. Patton LL. Out of the 29 cases in in this region of the world. In the first signal that the HIV/AIDS disease is progressing to a same study. people with HIV/AIDS. 15. In a major problem in the management of HIV/AIDS patients our study. In a study Clin Infect Dis 15:414–421 .4%) females. 17. Dupont B. and predictors of mortality. Sec Care Dentist 11:59–62 [21. Graybill JR. fluconazole was stomach upset. Walker DM (1980) The prevalence and intra-oral distribution of Candida albicans in man. Finally. Reichert PA (2002) Oral manifestations in severe moral transgressions. Dunkel J (1992) Candidemia in a tertiary care nystatin. more expensive than nystatin and ketoconazole. lead to further immune impairment. these events were mild and in found to be superior to nystatin [10] In another published no way affected our study. 28]. We scrapings gave no evidence of candidiasis. our countries may of necessity be quite different from those study showed that women are more affected by the disease used in the developed world [26]. Bianchi PG. Chattopadhyay A (2006) (A3) HIV phenotypes. Addy M. and perform self- giving a male-to-female ratio of 1:1. reduce predisposing factors that patients. The risk of References developing oral candidiasis in HIV/AIDS was strongly related to the presence of other sexually transmitted disease. Bendick C.6%) of the 14 patients treated with systemic antifungal highly active antiretroviral treatment (HAART) is accessible. For this group. While candidiasis is a relatively In a similar study in Uganda. In tropical countries. and the number of sex partners ill: a cross sectional pilot survey. therefore. Bagg J (1991) Oral health in the terminally various sexual behaviors. In the developed countries. Ranganathan K. Fluconazole (diflucan) is another prescrip. However. Homosexuality and abnormal sexual acts are 2. 23]. For the treatment of oral candidiasis in HIV/AIDS ing world and that a high prevalence of oral candidiasis patients. Scheifele C. Nittayananta W. Parente F. It has the benefit of once a day dosing. Jones M. Cernushi M (1989) The diagnosis of male patients and six female patients admitted to having oropharyngeal candidiaisis in patients with the acquired immune deficiency syndrome: is endoscopy always necessary? Am J more than one sexual partner. Arendorf TM. 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