ORAL MEDICINEORAL MEDICINE

Oral Candidosis

GRANT T. M CINTYRE

isolated from oral candidoses in the Abstract: Oral candidoses are frequently encountered in the practice of dentistry. immunocompromised patient, and in Although most oral candidoses are symptomless, they can indicate the presence of an underlying systemic disease, and the persistence of oral candidosis following such individuals the course of oral appropriate conventional management may be one of the first signs of undiagnosed candidosis can be protracted and immunosuppression. The opportunistic pathogen is the most resistant to normal management commonly isolated species from oral candidal lesions; however, the non-albicans protocols. Candida spp. are also implicated in the aetiology of oral candidoses. The effective management of oral candidosis is dependent on an accurate diagnosis, identification and elimination of any predisposing factors (where possible), and the prescription of Organisms Involved in Oral either topical or systemic antifungal agents. Oral candidosis may have significant Candidosis implications for the general health of immunosuppressed patients, particularly when Although C. albicans is frequently caused by the non-albicans spp. and, in cases of severe immunosuppression, systemic identified in the aetiopathogenesis of candidosis can be life-threatening. This article outlines the clinical presentation and candidosis, other candidal species can be appropriate management for the commonly presenting oral candidal conditions. isolated from oral candidal lesions: Dent Update 2001; 28: 132-139 ! C. tropicalis; Clinical Relevance: Dental professionals should be aware of the clinical signs of ! C. pseudotropicalis; intraoral candidosis, the appropriate special investigations that may be required in ! C. glabrata; order to derive a definitive diagnosis, the significance of immunosuppression in oral ! C. krusei; candidosis and the appropriate methods of management of the condition. ! C. parapsilosis.

PREDISPOSING FACTORS ral candidosis is a collective term symptomless and can be a marker of A number of predisposing factors have O for the group of diseases that underlying immunosuppression, and are been identified, all with the common result from infection with Candida spp., therefore referred to as the ‘diseases of the feature of producing a change in the host– affecting both immunocompetent and diseased’. Immunosuppression is an commensal balance (altered oral immunocompromised individuals. (The important consideration for any homeostasis), allowing the proliferation of terms ‘candidosis’ and ‘’ are candidosis that either does not resolve the candidal organisms that results in synonymous: candidosis will be used rapidly with appropriate conventional candidosis. C. albicans normally co- throughout this article.) Non-candidal oral management, or recurs frequently. exists with Lactobacillus acidophilus in mycoses (, Oral candidal species can be identified the vegetative ( or blastospore) state; and geotrichosis) are extremely rare and as part of the oral commensal flora in 41% however, it can readily change to the generally diagnosed only in HIV-infected of the ‘normal’ population,2 and it is elongated cellular form (pseudohyphae) or individuals.1 The effects of oral impossible to eradicate Candida from the chlamydospore forms. C. albicans has candidosis may range from localized oral cavity completely. Candida spp. are weak pathogenicity and when an infections to acute, systemic disseminated opportunistic pathogens, resulting in imbalance occurs in the host–commensal disease. Oral candidoses are often disease when the host–commensal relationship this commensal organism has relationship is disturbed. Candida the opportunity to become pathogenic. albicans is the species most often The production of an endotoxin – an Grant T. McIntyre, BDS, FDS RCPS (Glasg.), cultured from candidoses in extracellular proteolytic enzyme – is Specialist Registrar, Dundee Dental Hospital and immunocompetent individuals; however, responsible for most of the adverse School, Dundee, Scotland. the non-albicans spp. are more frequently effects of the intraoral mucous membrane

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Factor Examples rectification should form an integral component of the overall patient Physiological Age (old and young), pregnancy management: the failure either to identify Trauma Ill-fitting dentures and orthodontic appliances or manage predisposing factors will Dietary factors High carbohydrate intake, deficiency states (iron, vit. B , folate) prevent the expedient resolution of oral 12 candidosis, and will most likely result in Endocrine Diabetes mellitus, Addison’s disease, Hypothyroidism recurrence. Where it is not possible to Malignancy Agranulocytosis, leukaemias eliminate predisposing factors, such as in Immune defects AIDS the long-term use of inhaled steroids or Xerostomia Drug-induced, Sjögren’s syndrome, radiation-induced where malignancy is present, the prophylactic prescription of an antifungal Disturbed oral flora Antibiotics (especially broad spectrum), steroids agent may prevent recurrence. ‘Other’ factors Smoking, hospitalization Immunocompromization is the single Table 1. Predisposing factors in oral candidosis. most important predisposing factor that should be considered in patients with oral candidosis, owing to the potential for in oral candidosis. carcinomata predispose to oral significant general health sequelae and, Predisposing localized and systemic candidosis. The therapeutic use of in severe cases of immunosuppression, factors can be classified as natural chemotherapy and radiotherapy in the patient’s immune response may factors, dietary factors, mechanical malignancy are associated with an become overwhelmed by systemic factors and iatrogenic factors or grouped increased risk of oral candidosis: the candidosis, leading to a life-threatening according to physiological factors, mechanisms are complex, but involve situation. The prophylactic prescription trauma, dietary factors, endocrine factors, these therapies having a direct effect on of an antifungal may not only improve life malignancy, immune defects, xerostomia, the rate of cellular turnover in the oral quality, but also life expectancy for the disturbed oral flora and ‘other’ factors. mucous membrane and reducing the severely immunocompromised patient. Table 1 summarizes the predisposing salivary flow, respectively. Oral factors in oral candidosis. candidosis may be one of the earliest The physiological factors – the signs of AIDS, and in HIV-infected CLASSIFICATION OF ORAL extremes of age – predispose to oral patients candidoses can affect multiple CANDIDAL CONDITIONS candidosis, as they are associated with intraoral sites.1 The first classification of oral candidosis an impaired host response. Xerostomia results in reduced flow and was proposed by Lehner in 1966.5 Lehner Mechanical irritation (from acrylic quality of saliva and predisposes to oral recognized two major subdivisions: dentures and orthodontic appliances) candidosis. The reduced effectiveness of may result in the breakdown of the the antimicrobial properties of saliva ! acute, including pseudomembranous integrity of the mucous membrane, (lysozyme, lactoferrin, the and atrophic candidosis; and destroying its intrinsic antimicrobial lactoperoxidase system, and salivary ! chronic, including atrophic and resistance,3 while the close contact of the glycoprotein4) favours the proliferation hyperplastic candidiasis. acrylic and mucous membrane prevents of Candida spp. salivary antimicrobial substances Broad-spectrum antibiotics, steroid The currently accepted classification6 (lysozyme, lactoferrin, the aerosols and smoking interfere with the lactoperoxidase system and salivary normal balance of the oral microbial flora glycoproteins) coming into contact with by removing the competition between the Primary oral candidoses (group 1) the invading microorganisms. various microorganisms for adherence ! Acute: Pseudomembranous, Some dietary factors such as a high and nutrition which, in health, limits the erythematous carbohydrate intake provide Candida growth and dissemination of fungi. ! Chronic: Pseudomembranous, spp. with ideal metabolites, whereas the Hospitalization may predispose erythematous, hyperplastic (plaque-like and nodular) deficiency states (iron, vitamin B12 and individuals to oral candidosis; patients in folate) may reflect the poor resistance of hospital may encounter microorganisms ! Candida-associated lesions: Candida- the intraoral and perioral tissues to to which they cannot mount an effective associated denture-induced stomatitis, infection by Candida spp. immune response, either because of angular cheilitis, median rhomboid glossitis Endocrine disturbances, the presence reduced immunocompetence as a result Secondary oral candidoses (group 2) of malignancy and immune defects (e.g. of ill-health or due to the exposure to ! Oral manifestations of systemic mucocutaneous candidosis (due to diseases AIDS) are associated with an inferior previously unmet potential pathogens. such as thymic aplasia and candidosis host response, particularly cell-mediated Following the discovery of a endocrinopathy syndrome) immunity. Furthermore, areas of ulcerated predisposing factor in a patient Table 2. Classification of oral candidosis (after mucous membrane associated with oral diagnosed with oral candidosis, its Holmstrup and Axéll6).

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Management ab Pseudomembranous candidosis in the immunocompetent patient is usually managed using topical agents alone, although use of systemic agents may be associated with increased compliance because pastilles and lozenges have an unpleasant taste (Table 4). In patients with AIDS, systemic antifungals are more Figure 1 (a and b). Widespread intraoral pseudomembranous candidosis. effective than topical agents. Patients who do not experience resolution of pseudomembranous is based upon clinically relevant bacteria. Although pseudomembranous candidosis within two weeks of the terminology and accounts for the candidosis is usually termed ‘acute’ in institution of antifungal therapy should limitations of Lehner’s original view of the short duration of the be referred for investigation of possible classification (see Table 2). As condition, in immunocompromised underlying disease. Pseudomembranous pseudomembranous candidosis can be individuals the condition is often of a candidosis in the immunosuppressed present for an extended period of time, chronic, protracted nature, and can last (e.g. AIDS) should be managed in particularly in immunocompromised for months (and even years). specialist centres. patients or in those using inhaled steroids, ‘pseudomembranous’ should be prefixed with ‘acute’ or ‘chronic’ as Diagnosis ERYTHEMATOUS appropriate.6 The diagnosis of pseudomembranous CANDIDOSIS The term ‘erythematous’ represents a candidosis can usually be based on the Erythematous candidosis may be termed more valid term than ‘atrophic’ for lesions clinical findings, although a swab of the ‘acute’ or ‘chronic’, depending on the that appear more ‘red’ than the lesion should be sent for culture and time factor in the course of the condition. surrounding mucous membrane, as sensitivity, and a phosphate-buffered The acute form was formerly known as redness of the mucous membrane may be saline rinse may indicate the fungal load ‘acute atrophic candidosis’, ‘antibiotic due to either atrophy or increased present within the patient’s mouth (Table sore tongue’ or ‘glossodynia’ and is now vascularity. 3). A smear may also be helpful in the known as erythematous candidosis. It As angular cheilitis and denture diagnosis of pseudomembranous often results from treatment with broad- stomatitis and median rhomboid glossitis candidosis; however, biopsy is not spectrum antibiotics, steroid preparations may have a combined bacterial and usually necessary. The identification of (e.g. inhalers), and short-course fungal aetiology, they are more the causative candidal species and any topical antibiotics. The tongue is most appropriately classified as Candida- resistance to proposed antifungal agents often affected, although any area of the associated lesions. will allow the clinician to provide oral mucous membrane is susceptible. effective patient management. Erythematous candidosis resulting from PSEUDOMEMBRANOUS CANDIDOSIS This condition (see Figure 1) is also Condition Swab Smear Oral rinse Biopsy Blood known colloquially as ‘thrush’. The tests* clinical lesions of pseudomembranous Pseudomembranous + + + – – candidosis are very characteristic. Non- adherent creamy white patches or flecks Erythematous + +(–) + – – are easily wiped from an underlying Hyperplastic + +(–) + +(–) + erythematous and bleeding mucous membrane. Commonly affected areas are Candida-associated denture- the soft palate, oropharynx, tongue, induced stomatitis + + + – + cheek and gingivae. Surprisingly, pain is Angular cheilitis + + + – + rarely reported. The pseudomembrane consists of a Median rhomboid glossitis + + + +(–) +(–) mesh of fungal hyphae containing *Blood tests include iron, vitamin B 12, folate, glucose entangled desquamated epithelial cells, +: Useful; – not useful; +(–) may be useful fibrin, keratin, necrotic tissue and Table 3. Appropriate laboratory investigations for oral candidosis.

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Condition Topical treatment Systemic treatment candidal leukoplakia and is characterized by irregular whitish Pseudomembranous Nystatin pastilles or amphotericin Fluconazole 50 mg tablet daily for raised plaque-like lesions on the B lozenges sucked four times daily 14 days or itraconazole 150 mg for 7–10 days capsule daily for 15 days buccal mucous membrane near to the commissures (see Figures 2 and 3). Erythematous Nystatin pastilles or amphotericin B Fluconazole 50 mg tablet daily for The tongue is rarely involved. The lozenges sucked four times daily for 14 days or itraconazole 150 mg 7–10 days. Stop offending antibiotic capsule daily for 15 days patient and referring dentist are often (where present). Oral rinsing after concerned about potential malignancy inhaling steroids (Figure 3). Lesions are usually Hyperplastic Miconazole gel applied to lesions Fluconazole 50 mg tablet daily for bilateral, do not have a surface that is four times daily until resolution. 14 days or itraconazole 150 mg easily removed, and can be extensive. Low-carbohydrate diet capsule daily for 15 days Most patients are smokers. Other Candida-associated Miconazole gel applied to fitting Fluconazole 50 mg tablet daily for candidal lesions may also be present, denture-induced surface of appliance and palate four 14 days or itraconazole 150 mg possibly angular cheilitis. stomatitis times daily for 7 days. Soak capsule daily for 15 days prostheses in 1% hypochlorite (acrylic) or 2% chlorhexidine (metal- based). 2% chlorhexidine mouthwash Diagnosis four times daily. Low-carbohydrate Biopsy may be considered appropriate diet in certain cases to exclude neoplasia Angular cheilitis Miconazole gel applied to lesions Fluconazole 50 mg tablet daily for (Table 3) and to diagnose hyperplastic four times daily until resolution. Soak 14 days or itraconazole 150 mg candidosis definitively. prostheses in 1% hypochlorite capsule daily for 15 days (acrylic) or 2% chlorhexidine Microbiological investigation in the (metal-based). 2% chlorhexidine form of swabs can help in clarifying mouthwash four times daily the presence of Candida in the Median rhomboid Nystatin pastilles or amphotericin Fluconazole 50 mg tablet daily for lesions, and a phosphate-buffered glossitis B lozenges sucked four times daily 14 days or itraconazole 150 mg saline rinse may be confirmatory of the for 7-10 days. Anti-smoking advice capsule daily for 15 days intraoral presence of the organism and Table 4. Management of the oral candidoses in immunocompetent patients. indicate the fungal load. Haematological investigations are also important to assess any underlying predisposing factors such as the prescription of broad-spectrum prescriptions should be advised to rinse deficiency of iron, vitamin B12 or folate antibiotics is the only oral candidosis their mouth after inhalation to ensure (Table 3). where pain is a common symptom. speedy resolution of erythematous candidosis. Moreover, routine oral rinsing after inhalation should be Management Diagnosis suggested as a preventive measure to all The condition is managed by The clinical diagnosis of erythematous people using inhaled steroid rectification of any predisposing candidosis may be confirmed by prescriptions. factors (e.g. smoking), provision of an microbiological analysis of the appropriate antifungal (either topically organisms cultured from a swab of the or systemically) and by institution of a lesion, and a phosphate-buffered saline HYPERPLASTIC low-carbohydrate diet (see Table 4). rinse may indicate the intraoral fungal CANDIDOSIS Sometimes the protracted nature of load (see Table 3). A biopsy provides no This chronic condition is also known as hyperplastic candidosis necessitates additional diagnostic value.

ab Management Cessation of treatment with the offending antibiotic medication usually leads to spontaneous resolution: however, this may not be possible and topical antifungals may be necessary prophylactically if the causative therapy is to be continued (Table 4). Figure 2 (a and b). Hyperplastic candidosis in an edentulous heavy smoker. Patients using inhaled steroid

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appliances should be sent for culture and sensitivity, while a phosphate- buffered saline oral rinse will indicate the intraoral fungal load. Blood tests form an essential part of the management of this condition, in order to identify any predisposing factors, which include the deficiency

states (iron, vitamin B12, folate) and Figure 3. Same patient as in Figure 2. Lesions possible undiagnosed diabetes Figure 5. Angular cheilitis. extend onto perioral skin. A biopsy was mellitus. A biopsy specimen provides performed to eliminate neoplasia. no additional diagnostic information. mouthwash can also be of benefit due to its antifungal action. combined and lengthy treatment. Management 5. Systemic antifungal agents (see Follow up is imperative to ensure The management of the condition Table 4) may be considered for complete resolution, and for persistent should follow the following lines: patients whose compliance may be lesions cryosurgery or surgical expected to be poor (such as excision should be considered unless 1. Correction of any predisposing elderly people in care), precluded by the size of the lesion. factors. immunocompromised patients and 2. Improved appliance hygiene: for patients with Newton’s Type 3 immersion of the appliance in a 1% Candida-associated denture- CANDIDA-ASSOCIATED hypochlorite solution for acrylic induced stomatitis (in addition to DENTURE-INDUCED appliances, or 2% chlorhexidine the application of miconazole oral STOMATITIS solution for metal-based dentures, gel to the palate and the fitting This condition is classified as a whilst sleeping. surface of the denture). Candida-associated lesion, as it may 3. Advice regarding a low- result from a combined bacterial/fungal carbohydrate diet. aetiology. Patients affected by 4. Prescription of antifungals. ANGULAR CHEILITIS Candida-associated, denture-induced Miconazole oral gel should be Angular cheilitis presents as erythema stomatitis are not usually aware of its applied to the fitting surface of the and crusting of the skin at the presence. Curiously, in full-denture appliance and the denture-bearing commissures of the lips (Figure 5). As wearers, the maxillary denture-bearing area four times daily (the antifungal a mixed bacterial/fungal aetiology may area is more often affected than the is most effective while the patient be present, it should be classified as a mandibular denture-bearing area. is sleeping due to the reduced Candida-associated lesion. Edentulous Newton7 classified this condition into salivary flow). Miconazole is elderly people are most commonly three distinct clinical categories: available over the counter as well affected by angular cheilitis. In most as on prescription, but should be cases of angular cheilitis, simultaneous ! Type 1: pinpoint erythema. avoided by patients concurrently intraoral candidosis is evident. A ! Type 2: diffuse areas of erythema being prescribed oral multifactorial aetiology has been and oedema of palatal mucosa. The anticoagulants. A 2% chlorhexidine proposed for this disease and includes: affected area is sharply demarcated from surrounding normal mucosa. ! infection by either Candida spp. or Angular cheilitis can accompany Staphylococcus spp. (sometimes this condition (Figure 4). both); ! Type 3: nodular, hyperplastic areas ! deficiency states: notably iron,

of mucosa with interspersed normal vitamin B12 and folate deficiency areas of mucosa. (these may also be identified in the anaemias and latent anaemias); ! undiagnosed or poorly controlled Diagnosis diabetes mellitus; The appropriate investigations for ! skin creasing due to advancing Candida-associated, denture-induced age; Figure 4. Newton’s Type 2 denture stomatitis stomatitis are outlined in Table 3. A affecting an edentulous patient. Note the food ! poor dentures with inadequate swab of the lesions, the fitting particles on the erythematous denture-bearing vertical component, allowing the surface(s) of dentures and orthodontic area. skin at the commissures to crease

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and retain saliva; The concomitant prescription of ! systemic disorders, e.g. diabetes topical and systemic antifungals for mellitus, HIV infection. angular cheilitis (where intraoral and/or intranasal reservoirs have been identified) may be regarded as a ‘belt Diagnosis and braces’ approach but should Haematological investigations are ensure speedy resolution. Systemic important to exclude deficiency disease antifungals are the treatment of choice

(ferritin, vitamin B12, folate); for angular cheilitis in importantly, a blood glucose assay may immunocompromised individuals, for Figure 6. Median rhomboid glossitis. highlight possible undiagnosed lesions resistant to topical measures diabetes mellitus, which may be a alone, and where compliance is likely to significant predisposing factor. be poor. Swabs of the commissures and the The failure to identify or treat a of smoking is an integral part of the anterior nares, and any potential reservoir of organisms will result in the management of patients with median intraoral reservoir for organisms angular cheilitis recurring. Sufferers rhomboid glossitis, in order to prevent (commonly the fitting surface of should be discouraged from any habits successive recurrences. dentures, the palate and areas of that involve contact of nose and mouth hyperplastic candidosis) should also be in close succession. Fabrication of new sampled. These samples are important full dentures should be delayed until OTHER CONDITIONS to identify the causative organism as angular cheilitis has resolved. These include cheilocandidosis, well as the nucleus of organisms, which mucocutaneous candidosis and chronic may be ‘feeding’ the angular cheilitis. oral multifocal candidosis. The reader is A phosphate-buffered saline oral MEDIAN RHOMBOID referred to a specialist text for further rinse should also be undertaken. This GLOSSITIS information. may detect the presence of Candida at The usual clinical manifestation of intraoral sites not otherwise sampled. median rhomboid glossitis is of a diamond-shaped depapillated LABORATORY erythematous patch on the midline of INVESTIGATIONS FOR Management the tongue dorsum (Figure 6). It is ORAL CANDIDOSIS The management of angular cheilitis classified as a Candida-associated The most appropriate laboratory (see Table 4) will depend on the lesion as a mixed microbiological flora investigations are outlined in Table 3. elimination of organisms from the may be implicated in the aetiology. Swabs, first moistened with sterile reservoir of infection and the treatment saline and then rubbed along the of any systemic sources of surface of the lesions, should be microorganisms. The empirical Diagnosis promptly submitted to the application of miconazole gel four The diagnosis is usually clinically microbiological laboratory with a times daily to the lesions is helpful, as based; however, a swab and a request for culture and sensitivity. it is active against both Candida spp. phosphate-buffered saline oral rinse These allow the identification of the and Staphylococcus spp., as well as should be carried out, as a mixed causative candidal species, which in other Gram-positive organisms; and aetiological flora may be identified. most cases is C. albicans. However, therefore will eliminate many cases of Biopsy is unnecessary, unless the identification of non-albicans infection. An alternative is fusidic acid diagnostic uncertainty still exists Candida spp. is of considerable (Fucidin), again applied four times daily following the microbiological relevance in the management of oral to the lesions, but this is generally only investigations and the lesion fails to candidosis – especially in the prescribed on the basis of a respond to antifungal agents. immunocompromised patient – as non- confirmatory microbiological report albicans organisms may not respond to exclusively identifying Staphyloccus common topical and systemic spp. as the causative organism. Management antifungals. If microbiology reveals an intraoral Treatment requires the prescription of A smear of the lesion may duplicate source of infection (commonly the topical or systemic antifungals. the information provided by a swab but fitting surface of a denture and palate) However, Nystatin and amphotericin B in cases of diagnostic uncertainty, may this must also be treated appropriately. are not palatable, and compliance may be indicated. Similarly, if organisms are identified in be poor, in which case systemic A phosphate-buffered saline oral the anterior nares, they must also be antifungals may be more effective rinse will determine the presence of treated. (Table 4). Advice regarding cessation Candida within the oral cavity; and

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high candidal counts correspond with and the departments of Dental Illustration at Glasgow Dental Hospital and School and Media high fungal loads in the diseased areas EFERENCES Services at the University of Dundee for their R of mucous membrane. 1. Samaranayake LP. Oral mycoses in HIV help in the preparation of the images. Biopsy is generally unnecessary for infection. Oral Surg Oral Med Oral Pathol 1992; the diagnosis of oral candidosis, except 73: 171–180. 2. Lynch DP. : History, classification where potential malignancy is one of the and clinical presentation. Oral Surg Oral Med provisional diagnoses. FURTHER READING Oral Pathol 1994; 78: 189–193. Blood investigations should be Samaranayake LP, Lamey P-J. Oral candidosis: 1. 3. Budtz-Jörgensen E. Etiology, pathogenesis, instigated where appropriate, in order to Clinicopathological aspects. Dent Update 1988; therapy, and prophylaxis of oral yeast infections. 15: 227–231. Acta Odontol Scand 1990; 48: 61–69. identify any deficiency states and Lamey P-J, Samaranayake LP. Oral candidosis: 2. 4. Oksala E. Factors predisposing to oral yeast undiagnosed or poorly controlled Diagnosis and management. Dent Update 1988; infections. Acta Odontol Scand 1990; 48: 71–74. diabetes mellitus, which may indicate 15: 328–331. 5. Lehner T. Classification and clinicopathological poor tissue resistance to candidal Lewis MA, Samaranayake LP, Lamey P-J. Diagnosis features of Candida infections in the mouth. In: and treatment of Oral Candidosis. J Oral Winner HI, Hurley R, eds. Symposium on infection. Maxillofac Surg 1991; 49: 996–1002. Candidal Infections. Edinburgh: E & S Livingstone, US Department of Health and Human Services. Oral 1966; pp.119-136. Health in America: A Report of the Surgeon 6. Holmstrup P, Axéll T. Classification and clinical General. Rockville, MD: U.S. Department of manifestation of oral yeast infections. Acta ACKNOWLEDGEMENTS Health and Human Services, National Institute Odontol Scand 1990; 48: 57–59. I thank Dr D. Felix of Glasgow Dental Hospital and of Dental and Craniofacial Research, National 7. Newton AV. Denture sore mouth: A possible School for providing the clinical photographs Institutes of Health, 2000. aetiology. Br Dent J 1962; 112: 357–360.

BOOK REVIEW The book concludes with a discussion of novel diagnostic Contemporary Issues in Oral Cancer. techniques and finally summarizes D. Saranath (editor). Oxford University certain of the more recent Press, 2000 (405pp., £25.00). ISBN 0 19 observations in the field of oral 565023 9. malignancy, considering their possible future applications in the management This multi-author text aims to provide of this disease. an up-to-date account of the The work is extensively referenced, pathogenesis and management of oral but a number of the illustrations lack cancer. It embraces the basic science, clarity and are difficult to interpret. pathology and clinical aspects of this There is a widespread and disease. unnecessary use of abbreviations No fewer than 29 authors have throughout the text. A number of contributed to this book, which these abbreviations are not in common comprises 17 chapters and runs to usage and this may be a source of some 405 pages in length. Ten of the irritation to the reader. contributors work at the Tata Memorial In summary, this book is very broad Centre and thus it is not surprising in its scope and perhaps, as a result, that the text is biased somewhat represents somewhat of a compromise, towards the issue of oral cancer in lacking a particularly authoritative South Asia. approach. However, it should appeal The first chapter addresses the to both clinicians and basic scientists epidemiology and possible prevention The text continues with chapters on who either have an interest in, or are of oral cancer, introducing the subject serological markers in head and neck involved with, the management of matter effectively, whilst chapter two malignancy, the possible aetiological patients with oral cancer. The provides an overview of the molecular role of viruses and a chapter devoted publication contains a very biology of the disease. This is an to chemoprevention. considerable amount of information intrinsically complex topic and, in Six chapters address therapeutic and at a cost of £25, notwithstanding parts, the grammatical style of the text modalities of oral cancer and, as well as some of the above criticisms, it does not encourage the reader’s grasp summarizing the more traditional represents good value for money. of the subject matter. approaches, the potential use of The following three chapters outline photodynamic therapy, immunotherapy John Hamburger immunological aspects of oral cancer. and gene therapy are also discussed. Birmingham Dental School

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