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Fungal Infections of the Oral Cavity Sayan Bhattacharyyaet al FUNGAL INFECTIONS OF THE ORAL CAVITY FUNGAL INFECTIONS OF THE ORAL CAVITY IJCRR Sayan Bhattacharyya1, Satarupa Ghosal Bhattacharyya2 Vol 05 issue 12 Section: Healthcare 1 Category: Review Department of Microbiology, AIIMS, Patna, India Received on: 21/05/13 2Dental Surgeon, Lucknow, India Revised on: 09/06/13 Accepted on: 21/06/13 E-mail of Corresponding Author: [email protected] ABSTRACT Fungi, both yeasts and filamentous types, can cause infection of different sites in the oral cavity like buccal mucosa, gingiva and tongue. They are also components of the normal oral microbiota. In specific settings like denture usage, immunodeficiency due to HIV infection and inhalational steroid therapy, fungi, especially yeasts can affect different sites of the oral cavity producing different types of lesions. Studying these infections is important since they might lead to complications if left untreated and usually respond quite favourably to correct and timely antifungal treatment. Keywords: Fungi, oral cavity, lesions. INTRODUCTION international in order to collect material for the Fungi are eukaryotic unicellular or multicellular article and summarise existing knowledge of the organisms producing various infections in man(1). oral mycoses. Infections of the different structures in oral cavity Normal microbial flora of the oral cavity can be caused by bacteria, viruses and fungi(2,3). The oral cavity abounds in a plethora of different Different practices like wearing dentures, microorganism like bacteria and fungi that cigarette smoking and immunosuppressive colonise or coat the different structures in the oral conditions like HIV infection and inhalational cavity. Bacteria like oral streptococci and steroid use predispose individuals to oral Hemophilus spp. commonly colonise the mouth infection by fungi(4). These infections are cavity of healthy subjects(6). Candida spp. also produced predominantly by yeasts belonging to constitute the microflora of approximately 25- Candida spp., although yeasts belonging to other 40% of normal subjects(7). Colonisation by genera as well as filamentous fungi can also Candida spp. increases significantly in settings cause these infections(5). Hence studying these like poor oral hygiene, old age, wearing dentures infections is very important for proper and inhalational steroid use(8,9,10,11 ). These factors understanding of pathogenesis and treatment. increase the risk of developing subsequent oral Studies aimed at reviewing the clinical features, candidiasis. pathogenesis and complications of oral infections Risk factors and how they predispose to oral by fungi are not many in number, fungal infections notwithstanding the fact that this entity is often Cigarette smoking encountered in the clinical setting. So we Smoking is a known predisposing factor for attempted to summarise fungal infections of the development of oral candidiasis. It has been oral cavity in a lucid and scientific manner. documented in-vitro by researchers that candidal Scientific literature search was carried out from adhesion and expression of virulence factors like various indexed journals, national and Int J Cur Res Rev, June 2013/ Vol 05 (12) Page 83 Sayan Bhattacharyyaet al FUNGAL INFECTIONS OF THE ORAL CAVITY aspartyl protease expression are enhanced in Zygomycosis is also frequently encountered in presence of cigarette smoking concentrate(12). this group of patients, contributing factors being Dry mouth hyperglycemia and ketoacidosis, the latter Dry mouth or xerostomia can be found in culminating in impaired neutrophil function(19). Sjogren’s syndrome, HIV infection and intake of Agents causing fungal infections of the oral certain drugs. These factors lead to impaired mucosa saliva production and consequent loss of a. Other than Candida spp., which is the protective lactoferrin, antibodies and Histidine- principal aetiological agent of oral candidiasis, rich protein, leading to increased colonisation and other fungi like Blastomyces spp., infection with Candida spp(13). Histoplasma capsulatum and Cryptococcus Inhalational steroid and broad-spectrum neoformans can also cause oral disease, as a antimicrobial use part of disseminated fungal infection(20). It has been shown in several studies that use of b. Histoplasmosis, caused by Histoplasma inhalational steroids and broad-spectrum capsulatum, a dimorphic fungus, can produce antibiotics alter the normal bacterial flora of the verrucous or granulomatous lesions (indurated mouth cavity and results in overgrowth of and painful ulcer) in any area of the mouth, Candida spp. by removing competition for especially tongue, gingiva or palate, usually as growth(14). a component of systemic infection, although Extremes of age primary affection has also been In extremes of age, mounting a robust protective documented(21). local immune response against yeast pathogens c. Aspergillus spp. have been implicated in becomes very difficult. This results in yeast sinusitis and further extension into the oral overgrowth and infection(14). cavity can cause involvement of the hard Wearing of dentures palate, resulting in manifestations like The acrylic in denture material along with its loosening of teeth. Oral aspergillosis has been surface irregularities promotes adhesion and graded from Grade I to Grade V according to colonisation by Candida spp. on oral cavity(15). severity(22). Besides, dentures lead to irritation of the oral mucosal lining and loss of epithelium, due to d. Similarly mucormycosis can extend into the which there is prompt colonisation with Candida oral cavity from Maxilla and nasal sinuses, spp.(16). manifesting mainly as spreading sinusitis or (23) HIV infection facial cellulitis with palatal ulcer . Rhizopus Oral candidiasis is very commonly encountered spp. is the principal agent associated with this in HIV infection. In fact, in this context it has disease entity, and the jaw is almost always (24) been found that oral candidiasis is the commonest involved . oral lesion in HIV infected patients. These lesions e. Rarely fungi, previously considered as are significantly associated with a CD4 T cell saprophytes, e.g. Rhodotorula spp. can cause count of less than 200/µl(17). infection of the oral mucosa, usually in the Diabetes mellitus immunocompromised host (HIV infected (25) Uncontrolled diabetes mellitus can predispose to patient) . oral candidiasis. Candidiasis is found more in Agents causing infection of the periodontal diabetics due to several factors like poor tissue glycemic control, usage of broad-spectrum Gingiva can be affected in oral candidiasis, risk antibiotics and reduced flow of saliva(18). factors being the same as enumerated before. Int J Cur Res Rev, June 2013/ Vol 05 (12) Page 84 Sayan Bhattacharyyaet al FUNGAL INFECTIONS OF THE ORAL CAVITY Histoplasma capsulatum , a dimorphic fungal Complications of oral mycoses pathogen, can also involve the gingiva, initially The chronic hyperplastic variant of oral producing plaque-like lesions that usually candidiasis(CHC), typified by parakeratinisation ulcerate later. It is usually associated with of epithelium and found exclusively in HIV- disseminated infection in about 66% cases(26). infected patients, carries a risk of malignant There is one report of Job’s syndrome (primary transformation. In studies it has been observed immunodeficiency along with eczema, recurrent that the risk of developing oral squamous cell skin and lung infections, elevated serum IgE, and carcinoma is about 60-66% when left untreated connective tissue and skeletal abnormalities), and minimal when treated early with antifungal presenting with gingival infection with Candida agents(32). High-risk groups like patients suffering albicans(27). from End-stage renal disease are at risk of Fungi and progression of dental caries developing invasive fungal infections from Oral According to recent research, Candida spp. have fungal infections (OFI)(33). got a possible role in precipitating dental caries. They can break down dietary carbohydrates to PATHOGENESIS from organic acids which help in the tooth decay. Candida spp. have several virulence factors like Besides, Candida spp. have the potential of adhesins of HWP (Hyphal wall protein) family breaking down collagen of teeth by expressing which are essentially glycoprotein in nature, the protein collagenase(28). besides possessing secreted aspartyl Clinical features proteases(SAPs) that can damage host tissues. Oral candidiasis usually manifests as This pathogen can show phenotypic switching or pseudomembranous, white patchy lesions (oral conversion to hyphal stage from yeast stage in thrush) distributed over buccal mucosa in HIV tissues, and can also form structured multilayered infected patients. The lesions often show yeast communities called biofilms which make erythematous raw areas when the plaques are them immune from host defenses and antifungal removed manually. Other types of lesions drugs administered. This type of biofilm described are atrophic in old patients and those formation has most consistently been using dentures, chronic hyperplastic in HIV demonstrated over dentures made up of infected patients and angular chelitis at angles of Polymethylacrylate(34). mouth(13). There is also a strong association On the other hand, zygomycetes like Rhizopus between oral candidiasis and Median rhomboid spp., causing mucromycosis ,can bind to collagen glossitis, a lesion characterised by central of blood vessels and induce self-phagocytosis by papillary atrophy,
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