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Home , Oral candidiasis

2015 self-study course four course

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Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. contact for credit. . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your us http://dentistry.osu.edu/sms-continuing-education answer form and click “submit” you will be directed to a page with a . RECORD or PRINT THE unique confirmation ID. phone CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. 614-292-6737 A: Your SMS number can be found in the upper right hand corner of your

ABOUT your monthly reports, or, imprinted on the toll free back of your test envelopes. The SMS FREE CE… number is the account number for 1-888-476-7678 your office only, and is the same for everyone in the office. . TWO CREDIT HOURS are issued for Q: How often are these courses fax successful completion of this self- available? study course for the OSDB 2015-2016 614-292-8752 biennium totals. A: FOUR TIMES PER YEAR (8 CE credits). . CERTIFICATE of COMPLETION is used to document your CE credit and e-mail is mailed to your office. [email protected] . ALLOW 2 WEEKS for processing and mailing of your certificate. . The Ohio State University College of web Dentistry is an American Dental dentistry.osu.edu/sms Association (ADA) Continuing Education Recognized Provider (CERP). Page 1 ORAL 2015 The purpose of this course is to review the types of oral candidiasis and how they present to better help clinicians and the dental team recognize and course treat all patients. In addition to reviewing the common types and presentations, this course will review the symptoms, differential diagnoses, four treatment options and contraindications, and answers to a few commonly asked patient questions. Case 2 CASE STUDIES A 43 year-old woman with a Case 1 noncontributory medical history presented for a routine dental A 67 year-old woman presented to treatment. The dentist noticed the dentist with a 6 month history of “white and red lesions” on the a midline palatal ulcer. The patient hard . The patient reported reported wearing her denture 24 that her husband told her she hours a day. The long-standing ulcer sleeps with her pushed to was causing the patient pain, but the roof of her . The patient she still continued to wear her also had a three week history of a around the clock. An “cut” near her left commissure, evaluation of the but otherwise was unaware of any revealed red patches on the palate lesions. The dentist consulted and a somewhat rough area on the with an oral pathologist, and an posterior portion of the denture. exam revealed a red area in the The patient was also taking central portion of the dorsal numerous medications which tongue, angular , and a contributed to dry mouth. The oral “kissing lesion” on the hard palate. written by mucosa and the denture were The white areas were thought to swabbed and cultured, and showed be slight caused by ashleigh n. briody, dds positive for albicans. The the chronic rubbing of her palate patient was treated with with her tongue while sleeping. edited by troches and advised to The culture was positive for ross white, bs soak her denture in a diluted . solution at night, during the rachel a. flad, bs treatment. After three weeks, the patient reported that the release date ulcer had healed and she was no October 26, 2015 longer experiencing any discomfort.

last day to take the course at no charge November 20, 2015

last day course is Multifocal Dr. Ashleigh Briody, available for credit Candidiasis The Ohio State University College December 31, 2017 with Central of Dentistry Papillary Longstanding Ulcer Dr. Ashleigh Briody, on the Posterior The Ohio State University College Hard Palate of Dentistry Page 2

Case 4 The patient was prescribed 100 mg of Fluconazole for one week, after stating she did not like the oral A 27 year-old black female presented to oral troches (Mycelex) and had trouble remembering pathologists at the dental clinic for evaluation of to take the troches five times per day. The patient oral mucosal lesions. The patient’s medical returned for routine treatment and no evidence of history was indicative for systemic was found. erythematosus with kidney involvement and the

patient was taking several immunosuppressive Case 3 medications, including ,

Hydroxychloraquine (Plaquenil), and A 70 year-old white male presented to the dental Mycophenolate (CellCept). The intraoral clinic with a six month history of a sensitive oral examination revealed numerous white plaques mucosa. His medical history signified that he had resembling curdled milk that wiped off with a liver transplant and that he had been taking gauze ,while the underlying mucosa was red and antirejection drugs – including and tender. The patient complained of pain when tacrolimus – for many years. He stated that he had eating and drinking. An exfoliative cytology was not been able to eat any spicy or hot-temperature performed and the results showed candidal foods for several months. He and his wife were hyphae admixed with epithelial cells. very frustrated with his symptoms, since he could only eat very bland food. The additional oral examination revealed red lesions at the commissures consistent with , a very smooth tongue (atrophic tongue), erythematous tissue on his palate, and alveolar mucosa consistent with denture .

Pseudomembranous Dr. Ashleigh Briody, Candidiasis in and The Ohio State Immunocompromised University College of Dentistry Patient

Due to the patient’s severely

immunocompromised status and complex

medical history, the primary care physician was

Denture Dr. Ashleigh Briody, The advised of the results and the patient was placed

Stomatitis Ohio State University on preventative regimen of 100 mg of College of Dentistry Fluconazole daily.

Summary A culture was performed, which came back positive for Candida, and the patient was placed As shown in these cases, proper diagnosis and on Clotrimazole troches (Mycelex). A systemic treatment of candidiasis will improve a patient’s antifungal medication, such as Fluconazole, was symptoms. Candidiasis can present in obvious or determined to conflict with one of his anti- very subtle ways. As the dental team, recognition rejection medications: tacrolimus. The patient was of the variations are very important because the also instructed to use over-the-counter oral cavity is our area of expertise. Many other Clotrimazole antifungal cream in the corners of his medical professionals are not familiar with the mouth and/or to lick the corners of his while different oral presentations of candidiasis, dissolving the oral troche. therefore patients go undertreated. This can result in delayed healing of wounds and Page 3 discomfort in a patient who would otherwise be the infection can cause the lesion to appear more cured by administration of . troublesome than normal.

ORAL CANDIDIASIS OVERVIEW Disease Spectrum & Presentation

Oral candidiasis is a fungal infection of the top The disease spectrum for candidiasis widely varies layer of the oral mucosa caused by Candida from an asymptomatic carrier state to life albicans. This very common dimorphic yeast threatening disseminated candidiasis. The exists in two forms: yeast (unicellular) and hyphal treatment for the spectrum of candidiasis also (multi-cellular). In the yeast form, the fungus is ranges from topical antifungal to very potent commensal with the host, but when the oral intravenous medications. Typically, oral conditions change, the yeast can transform into candidiasis is a very superficial infection and will the hyphal form, which is pathogenic. Up to 50% require minimal medication for resolution. of patients can have yeast as part of their normal However, in cases of the severely oral flora, with no signs or symptoms of disease. immunocompromised, the fungus can deeply Numerous factors and conditions can contribute invade the tissue and, if untreated, the disease to the development of an oral candidiasis can result in death. infection: immune status, oral mucosal environment, and the virulence of the Candida Oral candidiasis presents in a number of ways – strain. Previously, candidiasis was thought to only including pseudomembranous candidiasis, occur as an in patients erythematous candidiasis, denture stomatitis, who were inflicted with other diseases, such as hyperplastic candidiasis, and angular cheilitis. those that modify immune status. Candida is The most recognizable form of candidiasis – acute commonly seen in newborns, the elderly, and pseudomembranous candidiasis, also known as those individuals who are immunocompromised. thrush – presents as a white cottage cheese-like However, it can also be seen in otherwise healthy plaque on the buccal mucosa, palate, or dorsal individuals. tongue. These lesions wipe off with gauze or by scraping with a tongue blade, revealing an intact Common Causes mucosa underneath which could look normal or red. In some patients, no symptoms are reported, is a common side effect of many while others will report a bad taste or burning medications that treat a wide range of medical sensation in the mouth. This type of candidiasis conditions. These medications include, but are can develop acutely, after the use of broad not limited to, those that are used to treat spectrum antibiotics, or chronically, in depression, pain, hypertension, and insomnia. immunocompromised patients. In patients with Immunocompromised patients include those who pseudomembranous candidiasis, diagnosis can are HIV-positive, post-transplant patients taking be established with a clinical exam, exfoliative antirejection drugs, and those individuals with cytology, or culture. autoimmune diseases who take medications to suppress his or her immune system. FORMS OF CANDIDIASIS

Other patients who may be at an increased risk for Erythematous Candidiasis developing candidiasis include those with conditions of increased keratin. Lesions that The most common form of candidiasis is appear white in the mouth are caused by excess erythematous candidiasis. This presents as red keratin production, and because of this, they may areas and can occur on the tongue, oral be subjected to increased presence of yeast due commissures, and the palate. Some patients to the organism feeding on the extra keratin. report a burning sensation, while others report no , lichenoid mucositis, and oral symptoms. On the tongue, erythematous leukoplakias have all been connected to increased candidiasis often presents with a central “bald” keratin production. When Candida is present on a patch, referred to as central papillary atrophy preexisting white lesion, the body’s response to (formerly called median rhomboid ). Page 4 Patients also have presented with a generalized Chronic Hyperplastic Candidiasis smooth tongue which is known as acute atrophic candidiasis. The smoothness of the tongue results Another form of oral candidiasis is chronic from the papillae undergoing atrophy as a result hyperplastic candidiasis, also known as candidal of the yeast feeding on the keratin that is on the or hypertrophic candidiasis. In this dorsal surface of the tongue. A bald tongue presentation, the candidal colonies appear as resulting from candidiasis may be confused with a white plaques that cannot be wiped off. They

Vitamin B12 deficiency or other blood abnormality, often appear worrisome, as they mimic pre- which will be discussed in the differential neoplastic leukoplakia. The most common diagnosis section on Page 6. A simple culture can location for this form is the anterior buccal rule out candidiasis. mucosa.

Angular Cheilitis Less Common Forms of Candidiasis

When candidiasis presents in the corners of the Delayed healing in traumatic or aphthous ulcers mouth, it is referred to as angular cheilitis. This can be caused by a Candida infection. While a will appear as a red area with or without cracking non-healing ulcer may be concerning for a more or crusting in the commissures. Occasionally, the serious process, Candida should be ruled out redness at the corners of the mouth could be and/or treated before a is performed. caused by a cutaneous bacterial infection, with or without Candida present. Other less common forms of candidiasis include perioral candidiasis, chronic mucocutaneous candidiasis, and endocrine-candidiasis syndromes. In multifocal oral candidiasis, as seen in Case 2, the patient will present with angular cheilitis or central papillary atrophy with a “kissing” lesion on the palate from contact of the tongue to the palate. Perioral candidiasis is a fungal infection associated with -licking or chronic use of lip moisturizing products. The products can “seal in” the fungal organisms allowing them to flourish on the surface of the skin or lips. Chronic mucocutaneous candidiasis is associated with an immunologic defect.

DENTURE STOMATITIS

Dr. Ashleigh Briody, Acute Atrophic Another presentation of candidiasis is denture Candidiasis with The Ohio State University College of stomatitis, also called chronic atrophic candidiasis. Angular Cheilitis Dentistry This presents as red tissue on the palate

underneath a denture, varying clinically from small

red papules resembling petechiae to more Chronic Multifocal Candidiasis granular and diffuse areas of erythematous

change. This is caused by the denture rubbing Chronic multifocal candidiasis is a type of against the oral mucosa, creating a moist, warm candidiasis that includes several presentations of environment ideal for growth of this organism. oral candidiasis. Patients can have white lesions that wipe off and/or multiple red lesions on the In cases of denture stomatitis, typically the dorsal tongue, commissures, and the palate. Candida has colonized on the denture more than Although the clinical signs may be evident, the oral mucosa. A diagnosis of denture patients with chronic multifocal candidiasis may stomatitis is often rendered clinically, but a culture be completely asymptomatic. provides a more definitive result. In a dentate Page 5 patient who presents with denture stomatitis, it The culture tube is left at room temperature for 48- may be prudent to inquire if the patient is using a 72 hours. If positive, the agar will show creamy night guard or other device in the mouth that white colonies usually 1-3mm in diameter. If could harbor yeast. When culturing a patient with colonies of yeast are suspected intraorally, an suspected candidiasis, a swab should be taken exfoliative cytology can be performed. In this from the oral cavity and the denture. In order to procedure, a wet tongue blade is used to gently effectively swab the denture, the sterile cotton tip scrape the white lesion and the cells are then must be moistened with water prior to swabbing transferred to a glass slide and fixed with a high the inside of the prosthesis. As shown in the alcohol content hairspray. The slide is then figure below, in the bottom culture, the right side processed with a Periodic acid-Schiff stain which of the agar was from the swab of the palate of a highlights the cell wall of the fungi. patient with denture stomatitis and the left side of the agar is from the swab of the inside of the Differential Diagnosis denture. Also in the figure below, the top culture is negative for Candida, while the middle culture is Some patients with oral candidiasis may complain positive for Candida. In cases where the denture is of mucosal burning. Once Candida has been colonized by fungal organisms, it is important to treated or ruled out, if symptoms persist in the treat the denture with antifungals which will be absence of evidence of any disease process, a covered in the treatment section on Page 7. diagnosis of should be considered. Burning mouth (burning tongue) syndrome is an idiopathic neuropathic condition that can affect nerves that transmit signals about pain (burning), taste (metallic, foul, sweet, etc.), or texture (mouth feels too dry, mouth feels too wet, feels like cotton). A patient with burning mouth syndrome can have one, two, or three types of nerves involved. As mentioned earlier, the symptoms of an oral yeast infection are similar with the symptoms of burning mouth syndrome. The difference is that with burning mouth syndrome, the symptoms will persist in the absence of evidence of the disease (negative culture = no areas of concern). Treatment for burning mouth syndrome is limited since most research has been open-label trial: a clinician Candida Cultures Dr. Ashleigh Briody, The Ohio State suggests a treatment to a patient to complete and University College of then report back on whether or not that patient Dentistry found it effective. Since not very many clinical trials have been attempted in the treatment of DIAGNOSING CANDIDIASIS burning mouth syndrome, the current accepted treatment is a regiment of Clonazepam 0.25mg Diagnosis: dissolvable tablets. Caution should be used in prescribing this for patients who are already on At times, the diagnosis of candidiasis can be made anti-depression or anti-epileptic medications, as with just the clinical presentation. If the they may interfere. symptoms are present but the clinical exam is not definitive, a culture may be performed to confirm While less commonly seen, other possible the diagnosis. This is done by using a sterile diagnoses include iron deficiency , cotton tip applicator to swab the patient’s mouth, Plummer-Vinson Syndrome and then transfer the swab to Sabouraud's agar. deficiency. These conditions are usually Sabouraud's agar is used for and investigated after candidiasis is ruled out as the other fungi and is necessary for this procedure as etiologic factor and are explained further in the following sections. the lowered pH inhibits growth of most bacteria. Page 6 Iron-Deficiency Anemia sources of B12, since the majority of B12 comes from

animal products. Without B12, the complex needed Iron-deficiency anemia is the most common to facilitate stomach absorption cannot bind anemic condition in the world, has a similar together, resulting in further deficiency of the presentation to candidiasis, and can be caused by vitamin. Patients with pernicious anemia often several factors. These factors include increased report symptoms similar to other anemic blood loss, increased demand for erythrocytes, conditions such as fatigue, weakness, and decreased intake or absorption of dietary iron, and headache, which are often attributed to the an increased presence of yeast in the body. reduced oxygen in the blood. The oral symptoms Increased blood loss can occur from menstruation, present in Vitamin B12 deficiency include burning trauma, gastrointestinal disease, malignancy, or of the oral mucosa, which may or may not show other conditions. In children and pregnant atrophy. In comparison to the oral symptoms of women, there is an increased demand for candidiasis, it is clear why both of these conditions erythrocytes during human growth. If the body are in the differential. Blood tests to rule out cannot accommodate this demand, anemia could anemia or a culture to rule out candidiasis can be develop. helpful.

Decreased intake of iron may be seen in those with poor diet or patients who have trouble obtaining TREATMENT sources high in iron such as edentulous patients or elderly patients requiring assistance. One possible The treatment for oral candidiasis is antifungal reason for decreased absorption of iron is a medication. Most studies suggest that a topical condition that has gained much media attention antifungal will work best with patient compliance; over the last few years – gluten sensitivity. In however, each treatment has advantages and patients who report a sensitivity to gluten, disadvantages. It is important to note that oral digestion of foods with the plant protein gluten candidiasis requires a longer course of antifungal can result in severe chronic diarrhea. This will medication than is typically necessary to treat the reduce the ability of the intestine to absorb iron, genital form. potentially resulting in iron-deficiency anemia. Dissolvable Antifungal Treatments Plummer-Vinson Syndrome There are two types of oral dissolvable antifungal Plummer-Vinson syndrome can also be considered treatment available in the United States. in the differential for erythematous candidiasis. In Mycostatin pastilles and Clotrimazole troches are patients with this rare condition, iron-deficiency is both antifungal lozenges with a mild taste that present in addition to glossitis and trouble patients will dissolve in the mouth, slowly, five swallowing. The condition is worth mentioning times per day over the course of ten days. While due to the increased risk of those afflicted going some oral pathologists prefer this treatment on to develop oral or throat . This will option due to its success in treating candidiasis, clinically mimic candidiasis in that patients will this treatment option has some disadvantages as it report burning of oral mucosa, atrophy of the requires patient compliance to use the medication tongue papillae, and/or angular cheilitis. Blood a total of fifty times, and has also been reported to tests can be obtained to rule out this condition. cause nausea and vomiting. If a patient with Patients with this condition should be monitored intraoral candidiasis also shows signs of angular closely for malignancy and/or referred to cheilitis, he or she will be instructed to lick the otolaryngology. corners of their mouth while dissolving the troche to ensure the medication reaches the commissures. Vitamin B12 Deficiency (Pernicious Anemia)

Skin Creams Vitamin B12 deficiency, or pernicious anemia, is an uncommon anemia caused by poor absorption of There are two types of skin cream that can be B12. It is most commonly seen in older patients of northern European ancestry, and can also be seen useful in the treating of oral candidiasis. One in vegetarians and vegans who do not obtain other Page 7 alternative is to advise a patient to purchase over- prescribed as a 150mg tablet to be taken only one the-counter Clotrimazole antifungal cream to time. Since this is a systemic medication, massage into the commissures three to four times prescribing it to patients taking numerous other per day. This may be the more cost effective medications or altered liver status may be option. The other alternative is prescription contraindicated. Some of the contraindication Vytone cream (Iodoquinol and hydrocortisone) medications include: oral hypoglycemic agents, that should be used three to four times per day for coumarin-like drugs, phenytoin (Dilantin), the optimal resolution of candidiasis. This cream cyclosporine, rifampin, theophylline, rifabutin, and dispensed in a 1oz tube has both antibacterial and tacrolimus. antifungal properties. Some patients will report the use of lip ointment in the commissures as a In cases of non-resolution, Ketoconazole can be relief for the symptoms; however, this should be prescribed in a 200 mg tablet for one to two weeks. dissuaded. The lip ointments will “seal in” the This medication has severe interaction with yeast, allowing them to proliferate more, resulting erythromycin, however, and could alter the in residual or worsening clinical appearance of metabolism of a number of other medications. candidiasis. Lip products that had direct contact Patients with liver dysfunction or disease should be with the affected area prior to antifungal treatment closely monitored by a physician. should be discarded to prevent reinfection. Oral Suspensions Solution Two other oral suspensions are Itraconazole Another alternative for topical antifungal (Sporanox) and (Fungizone). treatment is a Nystatin solution. The instructions These should not be confused with the same for the Nystatin are to swish two teaspoons in the medications administered in other forms. mouth for at least one minute, but up to three Itraconazole for oral candidiasis can be minutes, and then expectorate. While most administered as 10 mL (100 mg) doses. The patients do not like the taste, or a treatment that solution is vigorously swished in the mouth and requires such a long contact time, Nystatin can also swallowed twice a day for one to two weeks. be used to soak dentures. Due to expensive cost, Patients with liver dysfunction or disease should be usually Nystatin is reserved only for patients with closely monitored, and this medication is metal on their denture or a partial denture. contraindicated with erythromycin, oral triazolam, Patients with complete dentures fabricated with and oral midazolam. Amphotericin B can be acrylic can treat their dentures in a solution of one administered in 1 mL (100 mg) doses. The patient tablespoon of bleach to one cup of water. It is should rinse and hold in the mouth for as long as important to explain to patients that the bleach possible four times daily for two weeks. solution should only be used for nonmetal Amphotericin B suspension has been reported to appliances because the bleach will oxidize the cause a rash and gastrointestinal symptoms but is metal. It also may be prudent to mention that not contraindicated with any medications in this store bought denture cleaners do not contain the form. Both of these oral suspensions require a fair ingredients to kill yeast thus are ineffective in amount of patient compliance and are not used treating candidiasis. The denture, or other oral routinely for oral candidiasis treatment. appliance, should be treated throughout the course of the oral antifungal medication. COMMONLY ASKED QUESTIONS

Fluconazole REGARDING CANDIDIASIS

A third alternative for antifungal treatment is Is this the same as a genital yeast infection? Fluconazole (Diflucan). Fluconazole is a systemic antifungal medication that is prescribed in 100 mg Candida can occur in the oral cavity, on the skin, tablets for oral candidiasis. The patient will take gastrointestinal mucosa, vulvovaginal and penile two tablets on the first day and then one tablet areas, as the ideal environment for Candida species daily for the next 7 to 14 days. In contrast, to grow is a warm moist area. Over 90% of genital Fluconazole for vaginal yeast infections is Page 8 yeast infections are caused by Candida albicans, stressed, taking antibiotics, taking medications the same fungus responsible for oral candidiasis. that cause dry mouth, or who have a hormone Similar to the oral cavity, an infection occurs when imbalance. Sometimes, the actual cause of the an imbalance in the normal healthy flora candidiasis may be hard to pinpoint. In patients (microorganisms) occurs, whether it be due to with chronic dry mouth, drinking water medication, pH change, or hormones, the yeast throughout the day to keep the oral mucosa can multiply. The yeast then will feed on the hydrated can be beneficial in preventing a pH surface layer of the mucosa contributing to the change that would allow for the yeast to outgrow symptoms. The symptoms range from burning or the normal oral bacteria. itching to cottage cheese-like plaques or discharge. Genital yeast infections can occur in CONCLUSION men and women, and the symptoms can be similar to other genital infections. There are many forms of oral candidiasis. Some

present in very classic ways and others are much Is candidiasis contagious? more subtle. The use of cytologic smears and

cultures can aid in the diagnosis. While oral While candidiasis is not considered contagious, in candidiasis is caused by the same organism as the right setting it can be passed from person to other forms, it requires a longer course of person. In a person with a healthy immune antifungals. It is crucial for the dental team to system, the opportunistic yeast would not explore all possible diagnoses to aid in the establish in the oral or genital area. However, if a treatment of the patient. susceptible individual, such as an immunocompromised patient, was exposed to the fungus, the patient could develop candidiasis as a result. Most often, Candida does not spread from person to person. References available upon request.

Are there any foods I should avoid?

Many patients hear the words “yeast infection” and inquire about a relationship with bread or other foods that contain yeast. The yeast in bread, wine, and beer – Saccharomyces cerevisiae – is a different genus and species than the pathogen responsible for most oral candidiasis infections. While over 90% of candidiasis is attributed to Candida albicans, and the majority of the rest attributed to other species in the genus Candida, a very small percentage (less than 1%) has been attributed to S. cerevisiae. In this very small percentage, it is ABOUT THE AUTHOR important to note that the researchers could not prove that S. cerevisiae was the sole organism. In ASHLEIGH N. BRIODY, DDS bread, wine, and beer, the yeast is processed to a point rendering the organism incapable of ASHLEIGH BRIODY GRADUATED FROM LOUISIANA STATE pathogenicity, thus bread and other yeast UNIVERSITY SCHOOL OF DENTISTRY IN NEW ORLEANS, LOUISIANA. containing products do not need to be avoided. SHE IS CURRENTLY A SECOND YEAR RESIDENT IN THE ORAL AND Ultimately, both yeast types are treated in a similar MAXILLOFACIAL PATHOLOGY PROGRAM AT THE OHIO STATE manner. UNIVERSITY COLLEGE OF DENTISTRY. HER FUTURE CAREER PLANS INCLUDE SUPPORTING A BIOPSY SERVICE AS WELL AS TREATING AND MANAGING PATIENTS WITH ORAL DISEASE. Why did I get a yeast infection in my mouth? DR. BRIODY CAN BE REACHED AT [email protected] Several factors can contribute to developing oral candidiasis. It can occur in patients who are Page 9 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is November 20, 2015

The difference between oral candidiasis and burning mouth syndrome is that burning mouth 1 T F syndrome symptoms persist in the absence of evidence of the disease.

Oral suspensions are the ideal treatment for oral 2 T F candidiasis due to the ease of patient SUBMITcompliance.

Oral candidiasis and vaginal candidiasis are 3 T F treated with the same duration of antifungals.

The yeast organism can thrive in the oral cavity 4 T F by feeding on the extra keratin that is present. d i r e c t o r ONLINE john r. kalmar, dmd, phd [email protected]

Most often, Candida does not spread from person program manager 5 T F to person. ross white, bs [email protected]

channel coordinator 6 The yeast form of candida is pathogenic and the SUBMITT F hyphal form is commensal. rachel a. flad, bs [email protected]

senior laboratory 7 T F Candidal leukoplakia is most common in the preparator anterior buccal mucosa and can be wiped off. katherine j. myers [email protected]

ONLINEIron-deficiency anemia has been linked to gluten 8 T F sensitivity.

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