ORAL CANDIDIASIS

Synonyms:
Candidosis
Thrush
Moniliasis

Overview

Candidiasis is an opportunistic infectious condition caused by a ubiquitous, saprophytic fungi of the genus Candida, which includes eight species of fungi, the most common of which is Candida albicans. Candidiasis is usually limited to the skin and mucous membranes. Common clinical types of mucocutaneous candidiasis include: oropharyngeal (affecting the oral cavity and/or pharynx), vulvovaginal (affecting the vaginal and vulvar mucosa), paronychial (affecting the nail beds and folds), interdigital (usually affecting the skin in between the fingers), intertriginous (affecting the skin of the submammary areas or the groin and/or scrotum). Systemic, invasive, infections of candidiasis can occur, especially in those patients with severe immunosuppression. The gastrointestinal tract, trachea, lungs, liver, kidneys and central nervous system are all potential sites for infection in disseminated systemic candidiasis and may result in septicemia, meningitis, hepatosplenic disease, and endocarditis.

Epidemiology

Oral candidiasis is predominately caused by Candida albicans, although other related Candida species may be involved. Candida is commensal organism and part of the normal oral flora in about 30% - 50% of the population, and is capable of producing opportunistic infections within the oral cavity when appropriate predisposing factors exist.

Etiology and Pathogenesis

Neville, et. al. have identified three general factors that may lead to clinically evident oral candidiasis. These factors are: (1) the immune status of the host, (2) the oral mucosal environment, (3) the particular strain of C. albicans (the hyphal form is usually associated with pathogenic infection). The following is a list of specific conditions that may predispose a patient to develop oral candidiasis.

1. Factors that alter the immune status of the host:
• Blood dyscrasias or advanced malignancy
• Old age/Infancy
• Radiation therapy/Chemotherapy
• HIV infection or other immunodeficiency disorders
• Endocrine abnormalities:
• Diabetes mellitus
• Hypothyroidism or Hypoparathyroidism
• Pregnancy
• Corticosteroid therapy/Hypoadrenalism

 

2. Factors that alter the oral mucosal environment:
• Xerostomia
• Antibiotic therapy
• Poor oral or denture hygiene
• Malnutrition/Gastrointestinal malabsorption
• Iron, folic acid, or vitamin deficiencies
• Acidic saliva/Carbohydrate-rich diets
• Heavy smoking
• Oral epithelial dysplasia

Diagnosis

The diagnosis of oral candidiasis is most frequently made on the basis of clinical appearance along with exfoliative cytology examination. This involves the histologic examination of intraoral scrapings which have been smeared microscope glass slides. A 10% - 20% potassium hydroxide preparation ("KOH prep") can be used for immediate microscopic identification of yeast cell forms. Alternatively, the slide containing the cytologic smear can be sprayed with a cytologic fixative and stained using PAS (Periodic acid - Schiff) stain prior to microscopic examination.

A biopsy of affected tissue may be indicated, especially when candidiasis is suspected in conjunction with some concurrent pathology, such as epithelial dysplasia, squamous cell carcinoma, or lichen planus.

It is also possible to culture Candida using a Sabouraud's agar slant to aid in the definitive identification of the fungal organism.

Clinical Presentation and Treatment

I. (Acute) Pseudomembranous Candidiasis

• Pseudomembranous candidiasis is the most common form of oral candidiasis.
  
  
• The most common sites include buccal mucosa, dorsal tongue, and palate.
  
  
• Most frequent etiologies include antibiotic therapy or immunosuppression.
  
  
• It appears as soft, creamy white to yellow, elevated plaques, that are easily wiped off affected oral tissues and leave an erythematous, eroded, or ulcerated surface which may be tender.

Rationale for Treatment: Topical vs. Systemic Drugs

• Topical antifungals are usually the drug of choice for uncomplicated, localized candidiasis in patients with normal immune function.
  
  
• Systemic antifungals are usually indicated in cases of disseminated disease and/or in immunocompromised patients.
  
  
• Duration of therapy: Medication should be continued for at least 48 hours after the disappearance of clinical signs of candidiasis along with complete healing and the absence of mucosal erythema. Some sources recommend drug therapy should be continued for 10-14 days regardless of the disappearance of clinical signs of candidiasis.

Suggested Medications for the Treatment of Pseudomembranous Candidiasis:

Topical antifungal medications:

1. Rx:
   Nystatin oral suspension 100,000 units/ml
   Disp: 300 ml (14+ day supply)
   Sig: Rinse with 1 teaspoonful (5 ml) for two minutes, use q.i.d. (after meals, and at bedtime) and spit out. NPO 1/2 hour. (Patient can be directed to rinse and swallow if there is pharyngeal involvement).
   
   
2. Rx:
   Clotrimazole troches, 10 mg
   Disp: 70 troches
   Sig: Let 1 troche dissolve in mouth 5 times per day for 14 days. Do not chew. NPO 1/2 hour.

Systemic antifungal medications:

1. Rx:
   Ketoconazole tablets, 200 mg
   Disp: 14 tablets
   Sig: Take 1 tab q.d. with a meal or orange juice for 14 days
   
   
2. Rx:
   Fluconazole tablets, 100 mg
   Disp: 15 tablets
   Sig: Take 2 tablets stat, then 1 tablet q.d. for 14 days
   
   
3. Rx:
   Itraconazole tablets, 100 mg
   Disp: 28 tablets
   Sig: Take 1 tablet b.i.d. with a meal or orange juice for 14 days

II. Chronic Hyperplastic Candidiasis

• The most common sites are the anterior buccal mucosa along the occlusal line, and laterodorsal surfaces of the tongue.
  
  
• The etiology may be idiopathic or associated with immunosuppression.
  
  
• The most common appearance is that of asymptomatic white plaques or papules (sometimes against an erythematous background) that are adherent and do not scrape off.
  
  
• Some sources believe that hyperplastic candidiasis may have the ability to promote the development of oral epithelial carcinogenesis.

Treatment of hyperplastic candidiasis:

• Use topical or systemic medications as was recommended for pseudomembranous candidiasis.

III. Chronic Atrophic (Erythematous) Candidiasis

• The most common site is the hard palate under a denture, but atrophic candidiasis may also be found on the dorsal tongue and other mucosal surfaces.
  
  
• The most common etiology is poor denture hygiene, and/or continuous denture insertion, but it may also be caused by immunosuppression, xerostomia, or antibiotic therapy.
  
  
• The most common appearance is that of a red patch or velvet textured plaque. When atrophic candidiasis occurs on the hard palate in association with a denture, it is frequently associated with papillary hyperplasia.
  
  
• Patients may complain of a burning sensation associated with this type of candidiasis.

Rationale for Treatment of Chronic Atrophic (Erythematous) Candidiasis

• It is important to remember to treat both the denture (if present) and the oral tissues. (The denture will act as a reservoir for the Candida and reinfect the tissues if they are not treated concurrently).

Suggested Medications for the Treatment of Chronic Atrophic (Erythematous) Candidiasis

Rx:
Nystatin ointment
or
Clotrimazole cream 1%
or
Miconazole cream 2%
or
Ketoconazole cream 2%

Disp: One tube (15 or 30 gm)
Sig: Apply thin coat of medicine to entire inner surface of denture after each meal for 14 days.*

IV. Median Rhomboid Glossitis

• Median rhomboid glossitis is a form of chronic atrophic candidiasis characterized by an asymptomatic, elongated, erythematous patch of atrophic mucosa of the posterior mid-dorsal surface of the tongue due to a chronic Candida infection. (In the past, median rhomboid glossitis was thought to be a developmental defect resulting from a failure of the tuberculum impar to retract before fusion of the lateral processes of the tongue).
  
  
• A concurrent "kissing lesion" of the palate is sometimes noted.
  
  
• Specific predisposing etiologic factor(s) for median rhomboid glossitis have not been clearly established.

V. Angular Cheilitis (Perleche)

• Clinical appearance is that of red, eroded, fissured lesions which occur bilaterally in the commissures of the lips and are frequently irritated and painful.
  
  
• The most common etiology is loss of vertical occlusal dimension, but it may also be associated with immunosuppression.

Suggested Medications for the Treatment of Angular Cheilitis

Rx:
Nystatin - triamcinolone acetonide ointment
or
Clotrimazole cream 1%
or
Miconazole cream 2%
or
Ketoconazole cream 2%

Disp: One tube (15 gm)
Sig: Apply to affected areas q.i.d. (after meals, and at bedtime) for 14 days.

Insurance coding: ICD-9-CM

112.0 Candidiasis, oral

Authored by F. John Firriolo, DDS, PhD

Dr. Firriolo is an Associate Professor in the Division of Oral Diagnosis and Oral Medicine at the University of Louisville, School of Dentistry.

Reference List

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2. Greenspan D. Treatment of oral candidiasis in HIV infection. Oral Surg Oral Med Oral Pathol Oral 1994;78:2, 211-5.
   
   
3. Lynch DP. Oral candidiasis. History, classification, and clinical presentation. Oral Surg Oral Med Oral Pathol 1994;78:2, 189-93.
   
   
4. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & Maxillofacial Pathology. Philadelphia: W.B. Saunders, 1995, p. 163-9.
   
   
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6. Silverman S, Gallo JW, McKnight ML, et. al. Clinical characteristics and management responses in 85 HIV-infected patients with oral candidiasis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:4, 402-7.
   
   
7. Rosenberg SW, Arm RN, eds. Clinician's Guide to Treatment of Common Oral Conditions. Baltimore: The American Academy of Oral Medicine,1997, p. 5-7.