J Clin Exp Dent. 2014;6(5):e576-82. Treatment of oral candidiasis Journal section: Oral Medicine and Pathology doi:10.4317/jced.51798 Publication Types: Review http://dx.doi.org/10.4317/jced.51798 Current treatment of oral candidiasis: A literature review Carla Garcia-Cuesta 1, Maria-Gracia Sarrion-Pérez 2, Jose V. Bagán 3 1 Dentist. Postgraduate in Oral Medicine 2 Associate profesor of Oral Medicine Unit. Department of Stomatology. University of Valencia 3 Chairman of Oral Medicine. Oral Medicine Unit. Department of Stomatology. University of Valencia. Head of the Department of Stomatology and Maxilofacial Surgery. Valencia University General Hospital Correspondence: Avd. / Maestro Rodrigo 13-16 Garcia-Cuesta C, Sarrion-Pérez MG, Bagán JV. Current treatment of oral 46015 Valencia, Spain candidiasis: A literature review. J Clin Exp Dent. 2014;6(5):e576-82. [email protected] http://www.medicinaoral.com/odo/volumenes/v6i5/jcedv6i5p576.pdf Article Number: 51798 http://www.medicinaoral.com/odo/indice.htm © Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488 Received: 19/06/2014 eMail: [email protected] Accepted: 26/07/2014 Indexed in: Pubmed Pubmed Central® (PMC) Scopus DOI® System Abstract Candidiasis or oral candidosis is one of the most common human opportunistic fungal infections of the oral cavity. This pathology has a wide variety of treatment which has been studied until these days. The present study offers a literature review on the treatment of oral candidiasis, with the purpose of establish which treatment is the most suitable in each case. Searching the 24 latest articles about treatment of candidiasis it concluded that the incidence depends on the type of the candidiasis and the virulence of the infection. Although nystatin and amphotericin b were the most drugs used locally, fluconazole oral suspension is proving to be a very effective drug in the treatment of oral candidiasis. Fluconazole was found to be the drug of choice as a systemic treatment of oral candidiasis. Due to its good antifungal properties, its high acceptance of the patient and its efficacy compared with other antifungal drugs. But this drug is not always effective, so we need to evaluate and distinguish others like itraconazole or keto- conazole, in that cases when Candida strains resist to fluconazole. Key words: Candidiasis, treatment, miconazole, fluconazole, nystatin. Introduction Table 1. Predisposing factors. The incidence of fungal infections has been increasing Systemic Local over the last decades, being more prevalent in developed Hormonal disorders Epithelial changes countries (1). An increase incidence of the infections is Physiological disorders Poor oral hygiene associated with some predisposing factors (Table 1) as Endocrine disorders Loss of vertical dimension the use of dentures, xerostomia, prolonged therapy with Immunologic disorders Poor fitting dentures antibiotics, local trauma, malnutrition, endocrine disor- Xerostomia Smoking ders, increased longevity of people, among other states Drug therapy that diminish the quality of defense of the individual (2). Alcohol Oral candidiasis is one of the most common clinical fea- tures of those patients infected with the human immuno- Oropharyngeal candidiasis is caused by the genus Can- deficiency virus [HIV], this manifestation was seen in dida; it is possible to isolate about 150 species. Many up to 90% of individuals infected with HIV (3). of these remain as a commensal micro-organism in hu- e576 J Clin Exp Dent. 2014;6(5):e576-82. Treatment of oral candidiasis mans, which could act as an opportunistic pathogens of- tion; Appropriate use of antifungal drugs, evaluating the ten associated with predisposing factors attributed to the efficacy / toxicity ratio in each case. organism, thereby causing acute or chronic infections When choosing between some treatments it will take (4). The most important of these species is C. albicans, into account the type of Candida, its clinical pathology which is most commonly isolated from the oral cavity and if it is enough with a topical treatment or requires a and is believed to be more virulent in humans, occurring more complex systemic type (8), always evaluating the in approximately 50% of the cases of candidiasis. ratio efficacy and toxicity (9). The different drugs are Clinically there are a number of different types of oral contained in table 3. candidiasis (Table 2). Therefore the choice of therapy is Regular oral and dental hygiene with periodic oral exa- guided by the type of candidiasis. mination will prevent most cases of oral candidiasis, so The diagnosis of oral candidiasis is essentially clinical it is need to make the patient aware of oral hygiene mea- and is based on the recognition of the lesions by the pro- sures. Oral hygiene involves cleaning the teeth, buccal fessional, which can be confirmed by the microscopic cavity, tongue, and dentures. As well as the use of anti- identification of Candida (5). The techniques available Candida rinses such as Chlorhexidine or Hexetidine, so for the isolation of Candida in the oral cavity include that they can penetrate those areas where the brush does direct examination or cytological smear, culture of mi- not. In addition, the need to remove the dentures at night croorganisms and biopsy which is indicated for cases of and wash it consciously, leaving it submerged in a disin- hiperplasic candidiasis because this type could present fectant solution like Chlorhexidine (10). dysplasias (6). This study provides a literature review of the treatment The treatment of oral candidiasis is based on four fun- of oral candidiasis and its objectives are to establish ge- daments (7): making an early and accurate diagnosis of neral guidelines for treatment of oral candidiasis; Assess the infection; Correcting the predisposing factors or un- the drug of choice for local treatment of oral candidiasis; derlying diseases; Evaluating the type of Candida infec- Assess the systemic treatment for oral candidiasis. Table 2. Clinical classification. Acute Chronic Other lesions Pseudomembranous Pseudomembranous Angular cheilitis Erythematous Erythematous Denture-associated erythematous Hyperplastic Median rhomboid glossitis Table 3. Antifungal agents. Vademecum. DRUG FORMULATION DOSE ADVERSE EFFECT Anfotericin b 50mg for infusion 100-200mg/6h Renal, cardiovascular, spinal and neurological Nystatin Suspension 60ml 4-6ml / 6h Well tolerated. Ointment 30g 2 to 4 applications / day Tablets 2 every 8h Uncommon Nausea, vomiting, gastrointestinal effects Clotrimazole Gel 1% 3 times / day Occasionally Skin irritation, burning sensation Tablets 10mg 5 times / day Miconazole Gel 100mg /6h Uncommon Burning, irritation, nausea, diarrhea, Ketoconazole Gel 2% 3 times/ day Nausea, vomiting Tablets 200mg 1-2/day Abdominal pain. Suspension 30 or 10cc Fluconazole Tablets 50 - 100mg/day Nausea, vomiting, diarrhea, abdominal pain. Suspension 10mg/ml Itraconazole Capsule 100-200mg/day Nausea, vomiting, diarrhea, abdominal pain. e577 J Clin Exp Dent. 2014;6(5):e576-82. Treatment of oral candidiasis Material and Methods As first choice for local treatment has been for years the A Medline-PubMed search was made using the fo- nystatin at doses of 100 000 IU/ml [5ml 4 times daily] llowing key words: “ oral candidiasis” OR “oral candi- and amphotericin b at 50mg [5ml 3 times per day]. This dosis” AND amphotericin, “oral candidiasis” OR “oral choice is because they are poorly absorbed by the in- candidosis” AND nystatine, “oral candidiasis” OR “oral testinal tract and therefore most of the antifungal is ex- candidosis” AND miconazole, “oral candidiasis” OR creted without undergoing any change, thereby reducing “oral candidosis” AND ketoconazole, “oral candidiasis” hepatotoxicity (14). However, the unpleasant taste and OR “oral candidosis” AND clotrimazole, “oral candidia- prolonged pattern compromise treatment compliance by sis” OR “oral candidosis” AND fluconazole, “oral can- the patient (14-16). didiasis” OR “oral candidosis” AND itraconazole, “oral Throughout the years it has been studying the effective- candidiasis” OR “oral candidosis” AND treatment, “oral ness of other drugs like fluconazole oral solution. Many candidiasis” OR “oral candidosis” AND “antifungal authors have focused on evaluating the efficacy and therapy”.The key words were validated by the MeSH safety of fluconazole oral solution for the treatment of [Medical Subject Headings] dictionary, with use of the oropharyngeal candidiasis, especially pseudomembra- boolean operator “AND” to relate them. nous type, giving good results, although many studies The following limits for inclusion of the studies were esta- are still needed (14-18). blished: articles published from 2000, publications in En- In a recent study conducted in 19 patients with pseudo- glish and Spanish and publications of studies in humans. membranous candidiasis show that fluconazole suspen- All systematic reviews, clinical trials, meta-analysis and sion in distilled water [2mg/ml] reaches a 95% cure. comparative studies were considered in this review. The guideline was to rinse with 5ml of the drug solution A total of 109 articles were identified, of which 30 were for 1 minute and then spit it out and repeat this action selected after reading the abstracts. Following analysis 3 times a day for 1 week. Another study which inclu- of the 30 articles, we finally included a total of 24, since ded 36 children with pseudomembranous candidiasis those publications that did not fit the aims of the present showed