Done By : Dina Shaban & Marah Khaled

Edited By : ‫خطيب نجيب‬

Lect. Date : 27-1-2019

Doctor : Dr.Azmi

Subject : Oral Candidosis

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 Oral Candidosis (candidiasis)

Background about fungi

▪ Fungi are widely spread in the world in different species, they live on the plants,
soil, air also in human and animals.
▪ The most important type of fungus is candida.
▪ Candida has different species, in human body we have (candida albicans, candida
tropicalis, candida glabrata, Candida pseudotropicalis, candidakruzei, candida kyfar)
▪ but the most common and the most pathogenic type is candida albicans.
▪ Candida albicans present in half people as part of commensal oral flora (does not
cause any disease) And this is what we call commensalism or carrier state.
✓ So, the presence of Candida in the mouth does not necessarily mean clinical infection.
▪ But if the immune system is compromised either locally in the mouth or
systemically this fungus can over load and cause infection, for that it is called
opportunistic infection (disease of diseased).
‫وجود الكانديدا في جسم االنسان ال يعني بالضرورة وجود انفكشنوعشان يصير االنفكشن الزم يصير خلل بمناعة الجسم‬
▪ Septicaemic candidosis (candidaemia) is a disease of a very poor prognosis.
▪

Microbiology of fungi
❖ Candida albicanscan present in two forms in nature:
1. Blasto-spore form (commensalism form)
which has anoval shape,but sometimes it transform to
a pathogenic form which called (mycelium, hyphae or
pseudo-hyphae)
2. Mycelium, hyphae or pseudo-hyphae (pathological
form)
It has thread shape.
‫فتحولها من شكل لشكل يجعلها معديه‬
Elongated organisms with
psudohyphea or germ tube

Blastospore form.
 Pathogenicity
(Mechanism of microbes to cause diseases)

▪ For the yeast to cause disease it has first to adhere to the surface (adhesion
enable the MO to cause an action).
▪ Once the MO adhere→ can exhibit it pathogenic effect on the surface.

(The Yeast mechanism of exerting the pathogenic effect)

1. By producing toxic substances
2. By producing lipolytic effect (lipid enzymes) or proteolytic enzymes (protein enzymes).
✓ And by these enzymes it can destruct and penetrate through epithelium

▪ In conclusion:
For the disease to take place in the patient, the MO has to be sick in a way or another, so
candidiasis is the disease of diseased people (The fungi does not infect healthy people).

# Three general factors may predispose to oral candidosis

systemic factors local factors microbial factor

* More than a single predisposing factor may be operating in a certain patient

1. (systemic factors) Factors that alter the immune status of the host:

1. Reduced immune status: HIV infection and immunodeficiency disorders

2. immunosuppressive drugs: such as (steroids, cyclosporine, broad spectrum
antibiotics ) ( Broad-spectrum antibiotics will kill all bacteria and provide very
wide space to fungi to grow and cause infection )
3. in Endocrine abnormalities:
▪ Diabetes mellitus
▪ Hypothyroidism or Hypo-parathyroidism ▪ Physiologic states: Old age /
▪ Corticosteroid therapy / Hypo-adrenalism Infancy / Pregnancy
▪ 5: 46 ▪ Radiation therapy 2 /
▪ Blood dyscriasis or advanced malignancy Chemotherapy
 2. (local factors) Oral mucosal environment:

▪ Xerostomia
▪ Antibiotic therapy
▪ Poor oral or denture hygiene
▪ Iron, folic acid, or vitamin B deficiencies
▪ Acidic saliva / Carbohydrate-rich diet
▪ Heavy smoking -Oral epithelial dysplasia

3. (Microbial factor) Particular strain of C. albicans. The hyphal form is usually

associated with pathogenic infection.

Clinical presentation of candida

Despite being a single MO, it can produce different clinical presentation of disease.
We have four lesions produced only by candida in the oral cavity.

clinically present as white lesions: clinically present as red lesions:

1) pseudomembranous candidiasis(thrush)
2) candida leukoplakia (Chronic
Hyperplastic Candidosis) which is the most
dangerous type, bcz it is potentially
malignant lesion
(more common than white lesions)
1) acute erythematous candidosis (acute
atrophic candidosis)
2) denture stomatitis (denture sore mouth)

Classification of oral candidosis

▪ Pseudomembranous candidosis(thrush): acute-chronic

▪ Acute erythematous candidosis (acute atrophic candidosis)
▪ Chronic erythematous candidosis (chronic atrophic candidosis)
▪ Candida associated denture stomatitis; denturesore mouth).
▪ Chronic hyperplastic candidosis (Candida leukoplakia)
▪ Chronic mucocutaneous candidosis
Pseudomembranous and acute erythematous
candidosis are the most common oral fungal
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infections in HIV / AIDS patients
 1-Pseudomembranous candidiasis:
▪ this disease present as a white membrane and can be sloughed(wiped) away
leaving underneath inflamed erythematous, eroded, or ulcerated
▪ Surface May be tender.

2-chronic hyperplastic candidiasis (candida leukoplakia):

▪ It appears as adherent asymptomatic white membrane (can’t be sloughed away)

▪ Common sites:
✓ Anterior buccal mucosa along the occlusal line (as a triangle shape)
✓ Latero-dorsal surfaces of the tongue

▪ Risk factors:
1. Male
2. 2.Smoker
3. 3.Denture wearer

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 Chronic hyperplastic candidosis was further subdivided into 4 groups based on
localization patterns and endocrine involvement including:

1. Chronic oral candidosis (candidal leukoplakia)

2. Endocrine candidosis syndrome
3. Chronic localized mucocutaneous candidosis
4. Chronic diffuse candidosis.

3- Chronic Erythematous (Atrophic) Candidosis(Candida-associated denture stomatitis):

▪ Red patch or velvet textured plaque one the denture bearing area Complain of a
burning sensation result from wearing denture overnight (denture bearing
mucosa mostly the hard palate)

▪ Causes:
1. yeast can bind to the denture more than mucosa and wearing denture
overnight will increase the contact between yeast and mucosa, so we will have
infection also saliva has antifungal agents and wearing dentures will prevent
the mechanical (washing effect) and chemical effect of saliva
2. Well-fitting and ill-fitting denture will traumatize the mucosa and that will
make a pathway for yeast penetration.

o Most common predisposing factors:

1. Poor denture hygiene 5. Continuous denture insertion
2. Immunosuppression 6. Xerostomia
3. Antibiotic therapy 7. Diabetes mellitus
4. Nutritional deficiency
Newton classification
(for denture stomatitis)
• Newton type one→ pinpoint red spots
• Newton type two→ red patch covering all denture bearing area
• Newton type three→red lesions with granular tissue (Newton type two +papillary
hyperplasia of the palate)

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 4-acute erythmeatus candidosis (antibiotic sore tongue)

▪ It happens and treated very fast.

▪ will cause red and painful mucosa which is atrophic and infiltrated with candida hyphae.
▪ May be associated with thrush.
Common in: HIV+ve, immunosuppressed patients and following
prolonged broad-spectrum antibiotic therapy.

Pseudomembranous and acute erythematous candidosis are the most

common oral fungal infections in HIV / AIDS patients

Diagnosis

To diagnose the fungal infection, we should do biological tests (swab & smear tests)
1-Swab test:
Done by rubbing the area with cotton swab → then put it in a tube in the lab and culture it
on a culture plate by using Sabouraud agar which is a selective media for yeast that prevent
bacterial growth → then the we put it in the incubator for 48 hrs. to detect the type and
number of species.
2-Smear test:
Fast test done by scraping the mucosa → then put it on slide → fixation → staining → put it
under microscope to observe the yeast especially the mycelium form of fungi.

▪ (swab test alone is not enough because the patient maybe carrier, so we should do the
smear test to know if the yeast is in blasto-spore form or in mycelium form ).

▪ All candida infection diagnosed by swab & smear tests except Candida leukoplakia

▪ Candida leukoplakia diagnosed by biopsy in addition to the swab & smear tests in order
to detect any dysplastic transformation. you do biopsy anD PAS stain to diagnose candidal leukoplakia

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 Oral lesions associated with Candida
There are another two diseases, these are not mainly caused by candida
infections that’s why they are called candida associated infections, for example:

1.Angular cheilitis:
▪ most of the cases are caused by fungi which come from saliva, but sometimes it
might be caused by bacteria or both (bacteria & fungi).
All causes give the same clinical picture (red, eroded fissured lesions, cracks,
erythema, bleeding, painful)
unilateral or bilateral in the commissure of the lip.

▪ The most common etiology:

1. Loss of vertical dimension
✓ (saliva will leak to the angle of the mouth which supposed to be dry)
2. Haematinic deficiency
✓ (for example B12, Folic acid or iron deficiency)

❖ Types of bacteria:
• Staph aureus
• B-hemolytic streptococci
➢ (usually found in the anterior portion of the nose), that’s why some doctors
assume that this bacterial infection may come from the nose. And sometimes
it might be caused by mix of them.

→ About 30% of patients with chronic erythematous candidosis (denture stomatitis) are
having angular cheilitis as well; the mouth and the denture are the source of fungi

2.Median rhomboid glossitis:

▪ A form of erythematous candidosis.

▪ Asymptomatic, elongated erythematous patch of atrophic
mucosa of the posterior mid-dorsal surface of the tongue.

❖ Etiology:
1. Developmental anomaly 2. Candidal infection

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 Median rhomboid glossitis is not necessarily rhomboid in shape, and may be
elevated!!!

Q: Is MRG a specific situation of acute erythematous candidosis?

The majority of these cases are fungal infections, but the are some cases which
are developmental anomalies.

Red slot in the middle of the tongue posteriorly, its differential diagnosis is
developmental anomaly. This anomaly is formed during tongue development, a
structure called tuberculum Impar which is found at the base of the tongue
between the two halves of the tongue. So, during intrauterine development this
part naturally should regress through the thyroidal duct and
finally it will form the thyroid gland.

➢ As a developmental anomaly in some patients, the tuberculum

impar-or part of it- fail to regress and the 2 halves of the tongue
will join leaving the tuberculum impar between them and will
appear as a red region in the middle of the tongue.
( It has the red color bcz it is not a part of the tongue, it has no
papillae to give it the whitish appearance)

How to differentiate between developmental anomaly and the infection?

✓ By doing swab and smear tests
→ If It was negative then its developmental anomaly, if positive then its fungal.

Treatment of fungal infection

▪ The first step is to take swap and smear, if you assumed a candida leukoplakia
infection we take biopsy.

❖ Fungal infection treated in 2 ways:

1. The first way: by improving the immune system (decreasing risk factors like Diabetes)
2. The second way: by giving the appropriate drug.

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 Antifungal agents
Either topical (cheap and low side effects) or systemic (hepatotoxic and nephrotoxic)

❖ Topical:

1- Nystatin (used for denture stomatitis)

2- Amphotericin B (used mainly for mycoses).

✓ NOTE: One of their disadvantages that they must be taken several times a day
and for a long period.

➢ Nystatin is taken 4 times a day for one month (it’s not swallowed, it should be
kept in the mouth so that the mucosa will absorb it but not absorbed in the GI ).

✓ Note: In cases of denture stomatitis you have to take in your considerations

that the denture is a source of infection so that it must be disinfected.

Treatment of angular cheilitis:

▪ if it’s caused by fungal infection then a cream (Like Nystatin) is not enough for the
angels of the mouth; a suspension must be given to resist the pathogens from saliva.
▪ If the culture shows only bacteria then its applied in the nostrils and on the angels
of the mouth.
▪ If its mixed, then use miconazole (which act as antifungal & antibacterial) as both
cream and gel.

In candida leukoplakia they found that when we give the patient miconazole – a systemic
antifungal agent – the lesion will suppress within 7 days and the dysplasia will disappear.
This give us an impression that the yeast is the cause of dysplasia.

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 Diagnosis of oral candidosis

▪ Clinical presentation
▪ Swab and culture
▪ Smear
▪ Biopsy

From slides:
❖ Smear test:
➢ 10% - 20% potassium hydroxide preparation can be used for immediate
microscopic identification of yeast cell forms.
➢ The slide containing the smear can also be sprayed with a cytologic fixative
and stained using PAS (Periodic acid - Schiff) stain or Gram stain prior to
microscopic examination.

❖ Swab and culture:

➢ Candida isolation
➢ Growth on a plate of special Media
➢ Incubation at 37° C for 48 hours
➢ Candida species identification Swab and culture:

❖ Biopsy & PAS stain

➢ Indicated only in cases of chronic hyperplastic candidosis

❖ Candida isolation
➢ Growth on a plate of special media
➢ Incubation at 37° C for 48 hours
➢ Candida species identification

Slides: 32, 44-47 & 51-53

doctor did not mention them.

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