Oral Candidosis
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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 Candida albicans 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 ‘candidiasis’ 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 (cryptococcosis, histoplasmosis Oral candidal species can be identified the vegetative (yeast 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 132 Dental Update – April 2001 ORAL MEDICINE 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). Dental Update –