Candidal species are carried as normal oral commensals by 50% of the population. Candida albicans is the most frequently isolated strain and can cause a spectrum of lesions.

Predisposing factors:

Local factors:

Xerostomia from drugs or radiotherapy

Antibiotic therapy, particularly broad-spectrum agents

Corticosteroids

Heavy Smoking

Dental appliances

Systemic factors:

Poorly controlled diabetes mellitus (neutrophil leukocyte defects)

Extremes of age

Nutritional deficiencies – Iron, Vitamin B12, Folic acid

Immunosuppressive drugs – corticosteroids, cytotoxic chemotherapy

Immunodeficiency – Hereditary / Acquired (HIV) SEE picture on right

Classidication of Candidiasis:

Acute Candidiasis

Pseudomembranous (Thrush)

White/creamy plaques, easy to wipe off – leaves erythematous base

Often palate – junction hard/soft, fauces. Can be chronic if immunocompromised

Erythematous/Atrophic

Presents as red lesions. Can be seen in :-

Denture-related stomatitis (mild inflammation and erythema of mucosa beneath denture, usually asymptomatic)

AB-induced stomatitis (generalised mucosal erythema following broad-spectrum antibiotics, eliminates normal oral flora)

Median Rhomboid glossitis (depapillated rhomboidal area in centre line of dorsum of tongue, anterior to circumvallate papillae, usually asymptomatic)

Chronic Candidiasis

Hyperplastic (Candidal Leukoplakia)

Persistent white lesions, often at commissures or buccal mucosa, cannot rub off, 50% speckled, varying levels of epithelial dysplasia and recognised risk of malignant transformation (between 9 and 40%).

Mucocutaneous Candidiasis (CMC) Syndromes

Localised – oesophagitis, iron deficiency with persistent oral candidiasis

Diffuse (Candida Granuloma) – granulomas, susceptibility to bacterial infections,

Endocrinopathy Syndrome – pernicious anaemia, hypoparathyroidism, hypoadrenocorticism, diabetes

Thymoma – myasthenia gravis, aplastic anaemia, defect of cell mediated immunity

Erythematous/Atrophic

 

Angular Stomatitis/Cheilitis

Multifactorial cause:- skin folding due to age, diabetes mellitus, nutritional deficiencies, denture wearing

Inflammation at commissures of lips, erythema possibly with yellow crusting

Rx. intra-oral infection of candida

Miconazole gel/cream effective for candida and staph. and strep., Fusidic acid cream effective for staph. aureus

Diagnostic tests

A smear from the affected region should be taken and stained (Gram’s stain or PAS) - see candida hyphae

A swab and an oral rinse should also be taken and sent for culture

Biopsy and histopathological examination is necessary to confirm chronic hyperplastic candidiasis – examine for possible dysplasia

Management

VITAL to consider why candidal infection has arisen – underlying systemic conditions? Always consider HIV in adult male where no other detectable cause

Control of any local causes/predisposing factors —antibiotic therapy, anaemia, xerostomia, folic acid deficiencies, smoking, may be enough to resolve the lesions.

Topical use of antifungals – Nystatin pastilles/suspension, or Amphotericin lozenges should allow the oral microflora to return to normal.

Miconazole gel can be coated onto the base of the denture, TDS, while the denture is being worn, for denture-induced stomatitis, and continued 1—2 weeks, until the inflammation has cleared and C.albican is eliminated.

Elimination of C.albicans from the denture base is important and can be achieved by soaking the denture in 0.1% hypochlorite overnight. Topical anti-fungals can only gain access to the palate if the patient leaves their dentures out while the tablets are allowed to dissolve in the mouth.

Systemic Itraconazole and Fluconazole, can be used for resistant cases.