ORAL CANDIDIASIS IN DIABETIC PATIENT

Presented by :
Erna Sung, drg., Sp.PM
Diabetes mellitus (DM) is a chronic metabolic
disease characterized by hyperglycemia due
to either a deficiency of insulin secretion or
resistance to the action of insulin or both.

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 Diabetes Diagnosis Criteria
according to ADA-2020

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(Source: http://medicalce.com/the-american-diabetes-association-ada-criteria-for-the-diagnosis-of-diabetes/?utm_source=ReviveOldPost&utm_medium=social&utm_campaign=ReviveOldPost)
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Diet Karbohidrat(berlebihan)
T2D
Glukosa dalam darah meningkat

Insulin diproduksi oleh sel beta

Reseptor insulin terganggu

Glukosa darah tinggi

Diabetes Mellitus
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 DIABETES & ORAL HEALTH

The oral manifestations and complications related to DM :

• Xerostomia • Lichen planus & lichenoid reaction

• Poor Oral Wound Healing
• Dental Caries
• Oral Infection (oral Candidiasis)
• Periodontal Disease

• Burning Mouth syndrome

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 ORAL CANDIDIASIS

Oral candidiasis is a common

opportunistic infection of the oral
cavity caused by an overgrowth of
Candida sp.  C. Albicans

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 ETIOLOGY

• Candida sp.. :
• Candida albicans
• Candida glabrata
• Candida parapsilosis
• Candida tropicalis
• Candida krusei

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• Candida sp. found in oral cavity up to 80% of healthy individual
as a comensal organism (Bagtzoglou, 2005)

• Candida  pathogenous  oral candidiasis, as it occurs in

diverse population at risk among which there are individual
infected HIV, deficiency nutritional, malignancies, or with
metabolic disorders like DM (Suarez et al, 2013)
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 EPIDEMIOLOGY & PREVALENCE

• The prevalence of OC in patients with DM  13.7 - 64%, many cases  asymptomatic

lesions. Candida sp. were isolated from the oral mucosa of patients DM consists of C.
albicans (75 to 86.5%), C. krusei (4%), C. glabrata (5%) (Martinez et al, 2013).

• Higher Candida sp. colonization rates were reported in patients with DM type 1 when
compared to DM type 2 patients (84% vs. 68%, respectively), while the percentage in
nondiabetic subjects was around 27% (Rodrigues et al, 2019)

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• Diabetic patients are more susceptible to infections, especially
fungal infections  a direct relationship between increased blood
glucose levels & the number of Candida hyphae in the oral mucosa.

• Oral candidiasis can be diagnosed by the differential patterns of

mucosal changes like erythematous, pseudomembranous, and curd-
like plaques (biofilms)

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 PATHOGENESIS

Diabetes Mellitus

Immune dysfunction Side effect of drugs Peripheral

used to treat diabetes neuropathy

Salivary gland dysfunction

 Salivary flow &/

salivary glucose levels
Candidiasis

Pseudomembranous Denture Angular Median rhomboid

candidiasis stomatitis cheilitis glossitis
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 PHYSIOPATHOLOGY AND ETIOLOGY RELATED TO THE OCCURRENCE OF ORAL CANDIDIASIS IN DIABETICS
Uncontrolled hyperglycemia (high HbA1c) and
high glucose levels in saliva
Lower salivary pH
.
Physiopathology
-Uncontrolled hyperglycemia may cause intensification in salivary glucose levels because in diabetics the basement membrane of the parotid
salivary gland is more permeable
-High glucose levels allow Candida sp. to multiply, even in the presence of normal bacterial flora
-During hyperglycemic episodes, the chemically reversible glycosylation products with proteins in tissues and the accumulation of glycosylation
products on buccal epithelial cells may sequentially increase the number of available receptors for Candida sp.
-Glucose suppression of the killing capacity of neutrophils, emphasizing colonization (immunosuppression)
-Glucose, maltose, and sucrose boost the adhesion of Candida to buccal epithelial cells
-The growth of Candida in saliva is accompanied by a rapid decline in pH, which favors their growth and triggers the extracellular phospholipase
(PL) and acid proteases, increasing the yeast adhesion to oral mucosal surfaces

Tissue response to injury is diminished -Diabetes mellitus (DM) is known to diminish the host resistance and modify the tissue response to injury. This can result in severe colonization,
even in the absence of any clinically evident oral candidiasis and possibly with further dissemination via the blood.

Oral epithelium -It is most probable that the host oral epithelium of patients with diabetes favors the adhesion of colonization and subsequent infection.

Poor oral hygiene The lack of control of the oral environment, especially concerning the prevention of dental caries (coronary, root, and periodontal), leads to a
higher rate of oral candidiasis, especially in DM older patients

Aging Diabetic women, orally colonized with Candida sp. have higher oral glucose levels than diabetics without oral Candida sp.

Gender
Prostheses Inadequate use of prostheses, together with inadequate hygienization, favours the growth of Candida sp.

Drugs Xerostomia (abnomal lack if saliva): Candida sp. stagnation and growth on oral tissues

(Source: Rodrigues et al., 2019) 14

 ACUTE PSEUDOMEMBRANOUS CANDIDIASIS

• Symptoms:
Burning sensation
Poor oral intake
Taste alteration & weight loss
Difficulty swallowing

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Signs:-
White papules  plaque (resemble milk curd)  wiped off  erythematous &
sometimes bleeding base.

Figure 2&3. Candidiasis, pseudomembranous type (Source: Regezi, Sciubba & Jordan, 2012)

Acute pseudomembranous candidiasis 16

 DENTURE STOMATITIS

Synonym :
• Chronic atrophic candidiasis
• Chronic erythematous candidiasis
• Denture sore mouth
• Denture-induced stomatitis
• Denture-related stomatitis
• Inflammatory papillary hyperplasia

Denture stomatitis  mild inflammation & erythema of the mucosa

beneath a dental appliance, usually a complete upper denture.

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 PATHOGENESIS

Increased
Plaques
C. Albicans enzymatic
accumulation Inflammation
colonization activity of
on denture
Candida

↓Salivary flow & ↓pH

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Clinical features :
 Asymptomatic
 Chronic erythema & oedema of the mucosa that contacts the
fitting surface of the denture
 Uncommon complications, which include:
• Angular stomatitis
• Idiopathic papillary epithelial hyperplasia

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Newton classification of denture-stomatitis

Newton type 1 Localized simple inflammation

or a pinpoint hyperaemia (Source: EAOM, 2014)

Newton type 2 Erythematous or generalized simple

type presenting as more diffuse erythema involving a
part of, or the entire, denture covered mucosa
(Source: EAOM, 2014)

Newton type 3 Granular type (inflammatory

papillary hyperplasia) commonly involving the
central part of the hard palate and the alveolar
ridge (Source: Glick, 2014)
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 ANGULAR CHEILITIS

• Angular cheilitis is inflammation typically seen at both commissures (angles)

of the lips.

• Coinfection  C.albicans & S. aureus

• Presdisposing factors :
• Vitamin B12 deficiency
• Iron deficiencies Angular cheilitis
• Loss of vertical dimension (Source: Jontell & Holmstrup, 2015)

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 Pathogenesis Angular Cheilitis

Disorder of lip
anatomical
relationship

Denture- Angular Denture

related stomatitis design faults
stomatitis

Deficiency
states

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Clinical features :
• Symptoms:
Dryness
Corners of the mouth
Burning sensation

• Signs :

• Commissures  roughly triangular areas of erythema & oedema.

• Epithelium at the commisurres  wrinkled & macerated  deep

fissures/cracks ulcerated, do not tend to bleed, superficial exudative crust.
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 MEDIAN RHOMBOID GLOSSITIS

 A depapillated rhomboidal area in the central line of the dorsum of the

tongue, just anterior to the sulcus terminalis

 Predisposed by:
 Smoking
 Denture wearing
 Corticosteroid sprays/inhaler
 HIV infection
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Clinical features:
 Asymptomatic
 Signs:
• An area of papillary atrophy, flat,
reddish/red-white/white
• Elliptical/rhomboidal in shape
• Symmetrically placed centrally  midline
of the tongue
Median rhomboid glossitis
• Just anterior to the circumvallate papillae (Source: Jontell & Holmstrup, 2015)

• Occasionally  hyperplastic / lobulated

exophytic
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 DIFFERENTIAL DIAGNOSIS

Diagnosis Differential diagnosis

Acute pseudomembranous
Coated tongue, diphteri
candidiasis
Erythematous candidiasis Glossitis, fellatio

Angular cheilitis Split papule - syphilis

Median rhomboid glossitis Geographic tongue

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DIAGNOSIS
• Anamnesis
• Clinical features
• Supportive examination:
• Mycology
• HPA
 Candida isolation in clinic and quantification from oral samples
Method Main steps Advantages Disadvantages

Smear Scraping, smearing directly onto slide Simple & quick Low sensitivity

Swab Taken by rubbing cotton-tipped swabs over lesional Relatively simple Selecting sampling sites critical
tissue

Imprint culture Sterile plastic foam pads dipped into Sabouraud Sensitive and reliable; can Reading above 50 CFU/cm2 can be
(Sab) broth, placed on lesion for 60 s; pad pressed discriminate between infected inaccurate; selection of sites difficult
on Sab agar plate and incubated; colony-counter and carrier states if no clinical signs present
used

Impression culture Maxillary and mandibular alginate impressions; Useful to determine relative Useful mostly as a research tool
casting in agar fortified with Sab broth; incubation distributions of the yeasts on oral
surfaces

Salivary culture Patient expectorates 2 mL saliva into sterile As useful as imprint culture Considerable chairside time; not
container; vibration; culture on Sab agar by spiral useful for xerostomics; cannot
plating; counting identify site of infection

Oral rinse Subject rinses for 60 s with PBS at pH 7.2, 0.1 M, Comparable in sensitivity with Recommended for surveillance
and returns it to the original container; imprint method; better results if cultures in the absence of focal
concentrated by centrifugation; cultured and CFU >50/cm2; simple method lesions; cannot identify site of
counted as in previous methods infection

PBS, phosphate-buffered saline; CFU, colony forming unit (Source: Jontell & Holmstrup, 2015)
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Direct smear from thrush. A. few yeast cells may be present as well, but it is large number of
hyphae which is diagnostic. B. Thrush. The surface layers of the epithelium are separated by
inflammatory oedema and are cole and infiltrated by neutrophils. (Source: Cawson & Odell, 2002)

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Treatment

• Key  Identification & elimination of any

underlying host predisposing factors.

• Similar to medication for standard patients

• Topical antifungal  sugar-free

• If topical antifungal is not successful

within 10 days  systemic antifungal.
 Antifungal Agents Used in the Treatment of Oral Candidiasis
Drug Form Dosage
Amphotericin B Lozenge, 10 mg Slowly dissolved in mouth 3–4×/d after meals for 2wk minimum

Oral suspension, 100 mg/mL Placed in the mouth after food & retained near lesions 4× /d for 2 wk

Nystatin Cream Apply to affected area 3–4 ×/d

Pastille, 100,000 U Dissolve 1 pastille slowly after meals 4×/d, usually for 7 d

Oral suspension, 100,000 U Apply after meals 4 ×/d, usually for 7 d, & continue use for several days
after postclinical healing
Clotrimazole Cream Apply to the affected area 2–3x/d for 3–4 wk

Solution 5 mL 3–4x/d for 2 wk minimum

Miconazole Oral gel Apply to the affected area 3–4x/d

Cream Apply 2x/d & continue for 10–14d after the lesion heals

Ketoconazole Tablets 200–400-mg tablets taken 1-2x/d with food for 2 wk

Fluconazole Capsules 50–100 mg capsules 1x/d for 2–3 wk

Itraconazole Capsules 100 mg /d taken immediately after meals for 2 wk
Source: Jontell & Holmstrup, 2015
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Prognosis  Good, if:
 Controlled blood
glucose levels
 Maintained OH
 Sugar-free diet
 Taken medication
regularly

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Well-controlled blood glucose levels
is important for infection prevention
& proper healing in patient DMs.

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