Dr Preeti Sharma Reader Oral & Maxillofacial Pathology SDC
Dr. Preeti Sharma, Subharti Dental College, SVSU Candidiasis Phycomycosis Blastomycosis Aspergillosis Histoplasmosis Coccidioidomycosis Cryptococcosis
Dr. Preeti Sharma, Subharti Dental College, SVSU CANDIDIASIS Refers to multiplicity of diseases caused by yeast like fungus Candida albicans Most common oral fungal infection in humans Most opportunistic infection in the world Exists in 3 forms: Yeast form Pseudohyphae form Chlamydospore form
Dr. Preeti Sharma, Subharti Dental College, SVSU Predisposing Conditions 1. Acute & Chronic diseases 2. Endocrinopathies 3. Immunodeficiency 4. Nutritional deficiencies 5. Prolonged hospitalization 6. Prolonged drug therapy 7. Radiation therapy 8. Use of i.v. tubes, catheters, heart valves & poorly maintained dentures, heavy smoking 9. Old age, infancy, pregnancy
Dr. Preeti Sharma, Subharti Dental College, SVSU C/F: May range from mild superficial mucosal involvement to severe, fatal disseminated form seen in Immunocompromised patients
Dr. Preeti Sharma, Subharti Dental College, SVSU CLASSIFICATION OF ORAL CANDIDIASIS PRIMARY I ACUTE FORMS Pseudomembranous (Thrush) erythematous
II CHRONIC FORMS . Hyperplastic . Nodular . Plaque like . Erythematous . pseudomembranous
Dr. Preeti Sharma, Subharti Dental College, SVSU Candida-associated lesions • Denture stomatitis • Angular cheilitis • Median rhomboid glossitis Keratinized primary lesions superinfected with Candida • Leukoplakia • Lichen planus • Lupus erythematosus
Dr. Preeti Sharma, Subharti Dental College, SVSU Secondary oral candidiasis • Oral manifestations of systemic mucocutaneous candidiasis as a result of diseases such as a thymic aplasia and candidiasis endocrinopathy syndrome.
Dr. Preeti Sharma, Subharti Dental College, SVSU Acute Pseudomembranous Candidiasis m/c in debilitated, chr. ill, infants M/c site – buccal mucosa, tongue. Palate, gingiva, floor of mouth Symptoms – mild burning sensation, unpleasant taste (salty/bitter), feeling of ‘blisters’ Soft white elevated plaques, “ milk curd” or “Cottage Cheese”
Dr. Preeti Sharma, Subharti Dental College, SVSU White plaque can usually be wiped away with a gauze, leaving either a relatively normal appearing mucosa or an erythematous area
HISTOLOGICAL FEATURES
• Tangled masses of fungal hyphae with intermingled desquamated epi., keratin, fibrin, necrotic debris, leukocytes, bacteria
Dr. Preeti Sharma, Subharti Dental College, SVSU Dr. Preeti Sharma, Subharti Dental College, SVSU Erythematous candidiasis
• Acute atrophic candidiasis/antibiotic sore mouth • Central papillary atrophy of the tongue • Chronic multifocal candidiasis • Angular cheilitis • Cheilocandidiasis • Denture stomatitis/ chronic atrophic candidiasis.
Dr. Preeti Sharma, Subharti Dental College, SVSU Acute Atrophic Candidiasis (Antibiotic Sore Mouth) Develop as sequelae or de novo Appears red/ erythematous Consistently painful, burning sensation Bald tongue – loss of filliform papillae
Dr. Preeti Sharma, Subharti Dental College, SVSU
Chronic Atrophic Candidiasis (Denture sore mouth) Denture Stomatitis Erythema & petechial hemorrhage localized to maxillary denture bearing area
Dr. Preeti Sharma, Subharti Dental College, SVSU • The process is rarely symptomatic. • Patient admits to wearing dentures continuously, removing it only periodically to clean it. • Whether this represents actual infection by C.albicans or is simply a tissue response by the host to the various microorganisms living beneath the denture remains controversial.
Dr. Preeti Sharma, Subharti Dental College, SVSU • The clinician should also rule out the possibility that this reaction could be caused by improper design of the denture (which could cause unusual pressure on the mucosa), allergy to the denture base, or inadequate curing of the denture acrylic.
Dr. Preeti Sharma, Subharti Dental College, SVSU • If the palatal mucosa & tissue contacting surface of the denture are swabbed & separately streaked onto a Sabouraud’s agar slant, the denture typically shows much heavier colonization by yeast.
Dr. Preeti Sharma, Subharti Dental College, SVSU CENTRAL PAPILLARY ATROPHY • A form of erythematous candidiasis which is asymptomatic and chronic. It is also known as median rhomboid glossitis of the tongue. • In the past, this was thought to be a developmental defect of the tongue, occuring in 0.01 to 1% of adults. • The lesion was supposed to have resulted from a failure of the embryologic tuberculum impar to be covered by the lateral processes of the tongue.
Dr. Preeti Sharma, Subharti Dental College, SVSU • Now, a consistent relationship between the lesion and C.albicans has been noted. • Clinically, central papillary atrophy appears as a well-demarcated erythematous zone that affects the midline, posterior dorsal tongue and often is asymptomatic. • Erythema is due in part to the loss of filiform papillae in this area.
Dr. Preeti Sharma, Subharti Dental College, SVSU • The lesion is usually symmetric. • Often the mucosal alteration resolves with antifungal therapy. • Some patients with central papillary atrophy may also exhibit signs of oral mucosal candidal infection at other sites. This presentation of erythematous candidiasis is termed as chronic multifocal candidiasis.
Dr. Preeti Sharma, Subharti Dental College, SVSU • The junction of the hard and soft palate and the angles of the mouth may be involved. • Palatal lesion appears as an erythematous area that, when the tongue is at rest, contacts the dorsal tongue lesion, resulting in what is called a “kissing lesion” because of the intimate proximity of the involved areas.
Dr. Preeti Sharma, Subharti Dental College, SVSU Angular cheilitis, perleche
• Involvement of the angles of the mouth is characterized by erythema, fissuring, and scaling. Sometimes, it is seen as a component of chronic multifocal candidiasis, but it often occurs alone, typically in an older person with reduced vertical dimension of occlusion and accentuated folds at the corners of the mouth.
Dr. Preeti Sharma, Subharti Dental College, SVSU • Saliva tends to pool in these areas, keeping them moist and thus favouring a yeast infection. • 60% cases are due to combined infection with C.albicans and staphylococcus aureus. • The candidal infection may involve the perioral skin causing cheilocandidiasis.
Dr. Preeti Sharma, Subharti Dental College, SVSU Angular Cheilitis (Perléche)
Old patients with vertical dimension & accentuated folds at corners of mouth Erythema, fissuring, scaling at corners of mouth Pooling of saliva
Dr. Preeti Sharma, Subharti Dental College, SVSU Id Reaction
Hypersensitivity reaction to candidal antigen, which manifests as vesicular & papular rash on skin of patients with chronic candidiasis
Dr. Preeti Sharma, Subharti Dental College, SVSU Chronic hyperplastic candidiasis
• Also known as candidal leukoplakia. • In some patients with oral candidiasis, there may be a white patch that cannot be removed by scraping; in such case, the term chronic hyperplastic candidiasis is used. • Least common and is controversial. • Some believe that this condition simply represents candidiasis that is superimposed on a preexisting leukoplakic lesion. Dr. Preeti Sharma, Subharti Dental College, SVSU • However, the candidal organism alone may be capable of inducing a hyperkeratotic lesion. • Such lesions are usually located on the anterior buccal mucosa & cannot clinically be distinguished from a routine leukoplakia. • Often the leukoplakic lesion associated with candidal infection has a fine intermingling of red and white areas, resulting in a speckled leukoplakia.
Dr. Preeti Sharma, Subharti Dental College, SVSU • Such lesions may have an increased frequency of epithelial dysplasia histopathologically. • Diagnosis is confirmed by the presence of candidal hyphae associated with the lesion & by complete resolution of the lesion after antifungal therapy.
Dr. Preeti Sharma, Subharti Dental College, SVSU Histopathological features
• Candida seen in • exfoliative cytologic prep • tissue section from biopsy • Hyphae & pseudohyphae – must for Dx • Thickness of parakeratin with elongation of rete ridges • Chronic inflammatory cell infiltrate subjacent to infected epi • Micro abscess in parakeratin layer & supf spinous layer Dr. Preeti Sharma, Subharti Dental College, SVSU Hyphe stained by PAS growing towards epithelium
Dr. Preeti Sharma, Subharti Dental College, SVSU Chronic Mucocutaneous Candidiasis Chronic candidal involvement of the skin, scalp, nails and mucous memb. Oral lesions appear as thick white plaques that don’t rub off Similar to hyperplastic candidiasis Familial type is an inherited disorder, autosomal recessive, before age 5
Dr. Preeti Sharma, Subharti Dental College, SVSU Localized type: severe form Seen early in life No genetic transmission Widespread skin involvement Granulomatous & horny masses on face & scalp ↑ incidence of other fungal & bacterial inf. Primary site for white plaques → Mouth Nail involvement usually present
Dr. Preeti Sharma, Subharti Dental College, SVSU Diffuse Type: Least common form Late onset, pts. > 50 yrs. Extensive, raised crusty sheets involving limbs, groin, face, scalp etc. No family history
Dr. Preeti Sharma, Subharti Dental College, SVSU Candidiasis Endocrinopathy Syndrome • Genetically transmitted condition. • Candidiasis in association with various endocrinal abnormalities. • E.g. – Hypothyroidism, Hypoparathyroidism, Addison’s disease, Diabetes mellitus. • Also in association with Fe deficiency anaemia. • Enamel hypoplasia may be present.
Dr. Preeti Sharma, Subharti Dental College, SVSU Treatment
Antifungal agents Polyene agents – Nystatin, Amphotericin B Imidazole agents Triazole agents
Dr. Preeti Sharma, Subharti Dental College, SVSU REFERENCES
• Shafer’s Textbook of Oral Pathology. Eighth Edition. • Neville, Damm, Allen, Bouquot. Oral & Maxillofacial Pathology. Third edition. • Regezzi. Oral Pathology: Clinical Pathologic correlations. Seventh Edition.
Dr. Preeti Sharma, Subharti Dental College, SVSU