Oral candidosis. Clinical, historical, and therapeutic features of 100 cases

Benign Intraoral Soft Tissue Lesions in Children

Benign intraoral soft tissue pathology in pediatric patients includes developmental, traumatic, inflammatory, and infectious lesions. Common pathology includes gingival cysts, mucoceles, fibromas, and parulis. Less common lesions include peripheral ossifying fibromas, congenital epulis of the newborn, and congenital mandibular duct atresia. Most of these lesions present at painless masses but can have significant effects on children and their caregivers. Although these lesions are generally harmless, evaluation and treatment is necessary for appropriate management and health of the child.

Characterization of Oral Candida spp. Biofilms in Children and Adults Carriers from Eastern Europe and South America

BACKGROUND

Candida albicans and non-Candida albicans Candida species (NCACs) are known to colonize and invade various tissues, including the oral mucosa. In this work, we aimed to characterize mature biofilms of several Candida spp. clinical isolates (n = 33) obtained from the oral mucosa of children, adults, and elders of Eastern Europe and South America.

METHODS

Each strain was evaluated for its capacity to form biofilms in terms of total biomass using the crystal violet assay and for matrix components production (proteins and carbohydrates) using the BCA and phenol-sulfuric tests, respectively. The effect of different antifungals on biofilm formation was studied.

RESULTS

in the children's group, a predominance of C. krusei (81%) was observed, while, among adults, the main species was C. albicans (59%). Most strains showed a reduced response to antimicrobial drugs when in biofilm form (p < 0.01). Moreover, it was observed that strains isolated from children produced more matrix, with higher levels of protein and polysaccharides.

CONCLUSIONS

children were more likely to be infected by NCACs than adults. More importantly, these NCACs were able to form biofilms richer in matrix components. This finding is of clinical importance, particularly in pediatric care, since stronger biofilms are highly associated with antimicrobial resistance, recurrent infections, and higher therapeutic failure.

Otorhinolaryngology Manifestations of Systemic Illness

Ear-nose-throat (ENT) manifestations are among the most frequently observed clinical features of systemic illnesses. The patients often present with overt findings of head and neck lesions such as salivary gland swelling or lymphadenopathy. In contrast, patients may present with covert findings of auditory, nasal, and laryngeal symptoms that are less obvious and are often overlooked. Therefore, clinicians should have a high index of suspicion to identify the underlying disease. Early recognition and prompt treatment or referral to specialists may prevent morbidity and mortality. This article discusses various systemic illnesses with ENT manifestations that are commonly encountered.

Fungal Infections of Oral Cavity: Diagnosis, Management, and Association with COVID-19

The frequency of fungal infections is increasing due to immunodeficiency viruses and immunosuppressive drugs. The most common fungal infection of the oral cavity is candidiasis. The existence of Candida can be a part of normal commensal; hence, the isolation of Candida in the absence of clinical symptoms should exclude candidiasis. The pathogenicity of Candida is witnessed as opportunistic when immune status is compromised. Oral fungal infections are uncommon, but when identified, these infections are associated with greater discomfort and are sometimes destruction of tissues. Cytology and tissue biopsy are helpful in confirming the clinical diagnosis. The management of oral fungal infections must strategically focus on signs, symptoms, and culture reports. This article reviews information on diagnosis and therapeutic management of aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, mucormycosis, and geotrichosis.

Dynamics of Mono- and Dual-Species Biofilm Formation and Interactions Between Paracoccidioides brasiliensis and Candida albicans

The oral cavity is a highly diverse microbial environment in which microorganisms interact with each other, growing as biofilms on biotic and abiotic surfaces. Understanding the interaction among oral microbiota counterparts is pivotal for clarifying the pathogenesis of oral diseases. Candida spp. is one of the most abundant fungi in the oral mycobiome with the ability to cause severe soft tissue lesions under certain conditions. Paracoccidioides spp., the causative agent of paracoccidioidomycosis, may also colonize the oral cavity leading to soft tissue damage. It was hypothesized that both fungi can interact with each other, increasing the growth of the biofilm and its virulence, which in turn can lead to a more aggressive infectivity. Therefore, this study aimed to evaluate the dynamics of mono- and dual-species biofilm growth of Paracoccidioides brasiliensis and Candida albicans and their infectivity using the Galleria mellonella model. Biomass and fungi metabolic activity were determined by the crystal violet and the tetrazolium salt reduction tests (XTT), respectively, and the colony-forming unit (CFU) was obtained by plating. Biofilm structure was characterized by both scanning electronic- and confocal laser scanning- microscopy techniques. Survival analysis of G. mellonella was evaluated to assess infectivity. Our results showed that dual-species biofilm with P. brasiliensis plus C. albicans presented a higher biomass, higher metabolic activity and CFU than their mono-species biofilms. Furthermore, G. mellonella larvae infected with P. brasiliensis plus C. albicans presented a decrease in the survival rate compared to those infected with P. brasiliensis or C. albicans, mainly in the form of biofilms. Our data indicate that P. brasiliensis and C. albicans co-existence is likely to occur on oral mucosal biofilms, as per in vitro and in vivo analysis. These data further widen the knowledge associated with the dynamics of fungal biofilm growth that can potentially lead to the discovery of new therapeutic strategies for these infections.

Increased levels of calprotectin in the saliva of patients with geographic tongue

OBJECTIVE

We investigated whether patients with geographic tongue have increased salivary levels of calprotectin and whether there is a correlation between the salivary levels of calprotectin and interleukin 8 (IL-8), which is another marker of inflammation.

METHODS

Twenty-three patients diagnosed with geographic tongue and 32 control subjects without oral mucosal lesions were included in the study. The patients with geographic tongue were classified based on clinical appearance and number of oral lesions. ELISAs were used to determine the levels of calprotectin and IL-8 in whole saliva samples.

RESULTS

There was a statistically significant increase in the salivary output of calprotectin in patients with geographic tongue compared with the healthy controls (62 ± 9,1 vs. 37,5 ± 4,7 µg/min; p = .0134). Furthermore, the levels of calprotectin correlated positively with the number of oral lesions in patients with geographic tongue. There was also a significant and positive correlation between the salivary levels of calprotectin and IL-8, both for the patients with geographic tongue and the controls.

CONCLUSION

This study supports the notion that GT is an inflammatory disease, in which the activation of neutrophils and production of calprotectin in the saliva may play roles in its pathogenesis.

Throat swabs have no influence on the management of patients with sore throats

BACKGROUND

Throat swabs are neither specific nor sensitive for micro-bacteria causing sore throat symptoms; however, current guidelines suggest they are still useful in some cases.

METHOD

Retrospective and prospective analyses were conducted of throat swabs requested within the months of January 2016 and August 2016, respectively.

RESULTS

The study comprised 247 patients. Fifty-nine (24 per cent) had a positive culture. Forty-six grew group A beta-haemolytic streptococci, with the remainder growing candida (n = 10), coliform (n = 1) and klebsiella (n = 2). There was no significant difference in culture rates between primary or secondary care sources (χ2 = 0.56, p = 0.45). None of the swabs influenced a variation in patient management from local antimicrobial policies. Current practice has an estimated annual financial impact of £3 434 340 on the National Health Service.

CONCLUSION

Throat swabs do not influence the antimicrobial treatment for patients with sore throats, even under current guidelines, and incur unnecessary cost. Current clinical guidelines could be reviewed to reduce the number of throat swabs being conducted unnecessarily.

Case Report: Diagnosis of hypogeusia after oral exposure to commercial cleaning agent and considerations for clinical taste testing

Few reports in the literature document acute taste disturbance following exposure to toxic chemicals. We describe the case of a 54-year-old man who presented with primary complaint of tongue numbness and persistent problems with taste 1.5 years following oral exposure to a commercial cleaning agent. A test of olfaction revealed normosmia for age and gender. Lingual tactile two-point discrimination testing showed reduced somatosensation. Taste threshold testing using a 3-drop method demonstrated severe hypogeusia, though the patient was able to discriminate tastants at lower concentrations with a whole mouth swish and spit test. We conclude that clinical evaluation of dysgeusia can be performed using a number of previously published testing methods, however, determining causative factors may be confounded by duration since exposure, lack of knowledge of baseline taste function, and medications. Although many testing options exist, basic taste testing can be performed with minimal expertise or specialized equipment, depending on the patient history and goals of evaluation.

Case Report: Diagnosis of hypogeusia after oral exposure to commercial cleaning agent and considerations for clinical taste testing

Few reports in the literature document acute taste disturbance following exposure to toxic chemicals. We describe the case of a 54-year-old man who presented with primary complaint of tongue numbness and persistent problems with taste 1.5 years following oral exposure to a commercial cleaning agent. A test of olfaction revealed normosmia for age and gender. Lingual tactile two-point discrimination testing showed reduced somatosensation. Taste threshold testing using a 3-drop method demonstrated severe hypogeusia, though the patient was able to discriminate tastants at lower concentrations with a whole mouth swish and spit test. We conclude that clinical evaluation of dysgeusia can be performed using a number of previously published testing methods, however, determining causative factors may be confounded by duration since exposure, lack of knowledge of baseline taste function, and medications. Although many testing options exist, basic taste testing can be performed with minimal expertise or specialized equipment, depending on the patient history and goals of evaluation.

Candida species epidemiology 2000-2013: a laboratory-based report

OBJECTIVE

To describe a prospective laboratory-based surveillance of Candida species that were collected from different anatomical sites of patients admitted to the University of Malaya Medical Centre, Malaysia, from the year 2000 to 2013.

METHODS

Conventional (culture, microscopic examination and carbohydrate assimilation test) and molecular (PCR amplification and DNA sequencing) techniques were used to identify Candida species.

RESULTS

A total of 16 Candida species isolated from 34 392 clinical samples were from the oral cavity (oral swabs and throat swabs), blood, respiratory tract (sputum, tracheal secretions, nasopharyngeal aspirates, bronchoalveolar lavage), high vaginal swab, pus and urine. C. albicans (66.70%, 22 941/34 392), C. glabrata (11.71%, 4029/34 392), C. parapsilopsis (10.74%, 3692/34 392), C. tropicalis (9.19%, 3162/34 392) and C. krusei (1.15%, 396/34 392) were the five predominant Candida species. C. albicans was the predominant species isolated from the oral cavity, respiratory tract and high vaginal swab; while the Candida species isolated from blood, urine and pus were predominant non-albicans Candida. Uncommon Candida species, such as C. lusitaniae, C. haemulonii, C. humicola, Pichia ohmeri and C. ciferrii, were also isolated in this study.

CONCLUSION

Our study expands the current knowledge of the epidemiology of non-invasive and invasive candidiasis in Malaysia. The variability of the Candida species distribution from different anatomical sites highlights the significance of local epidemiology in disease management and selection of antifungal agents.

Shaping the oral mycobiota: interactions of opportunistic fungi with oral bacteria and the host

The oral mycobiota is an important component of the oral microbiota that has only recently received increased attention. The diversity and complexity of the oral mycobiota in healthy humans is greater than any other body site. Dysbiotic imbalance of indigenous fungal communities in immunosuppressed hosts has been proposed to lead to oropharyngeal fungal infections. As in other body sites, to survive and thrive in the oral cavity fungi have to maintain mutually beneficial relationships with the resident bacterial microbiota and the host. Here we review our current understanding of the composition of the oral mycobiota and how it may be influenced by oral commensal bacteria and the host environment.

Taste Disorders in Healthy “Carriers” and “Non-Carriers” ofCandida albicansand in Patients with Candidosis of the Tongue

Impairments in taste perception may be caused by a number of factors, including the presence of Candida albicans in the oral cavity. We attempted to establish whether the presence of Candida albicans on the tongue is a cause of taste disorders by studying taste disorders in patients with candidosis of the tongue and in healthy "carriers" and "non-carriers" of C. albicans. Taste disorders and their severity were objectively assessed by the filter-paper disk method in 18 patients with candidosis of the tongue and in 33 healthy "carriers" and 167 healthy "non-carriers" of C. albicans. The gustatory function was re-tested in 7 patients and 8 "carriers" after treatment with topical anti-mycotic medication to detect any improvement. Patients with candidosis of the tongue and "carriers" of C. albicans demonstrated significantly higher incidences (p<0.001) of taste disorders than did "non-carriers". The mean taste threshold of each of the four individual taste qualities was significantly higher in patients with candidosis than in "non-carriers". The average taste threshold was significantly higher in "carriers" than in "non-carriers". Post-treatment improvement or recovery from taste disorders was obtained in 5 out of 7 patients (71.4%) with candidosis and in 7 out of 8 "carriers" (87.5%) of C. albicans. This study clearly demonstrates that not only overt candidosis of the tongue but also commensal harboring of C. albicans is a cause of taste disorders.

Pediatric soft tissue oral lesions

This article provides an overview of common color changes and soft tissue oral nodular abnormalities in children and adolescents. The clinical presentation and treatment options to address these conditions are presented in a concise approach, highlighting key features relevant to the oral health care professional.

Update on oral fungal infections

The incidence of oral fungal infections has increased in recent years as a result of factors such as increased number of solid organ transplantations and the widespread use of immunosuppressive drug therapies. This article reviews the diagnosis and treatment of oral fungal infections. At one time oral fungal infections were a relatively uncommon event, but with advances in health care and polypharmacy in an increasingly aging population, these infections are becoming a more routine clinical finding. The dental practitioner therefore needs to be familiar with the diagnosis and management of oral fungal infections.

Candida and calcofluor white: Study in precancer and cancer

Background:

The interest in oral candidosis has waxed and waned from the period of Hippocrates. The acquired immune deficiency syndrome (AIDS) epidemic has certainly bolstered these figures on oral candidosis, with diabetes and oral cancer being no exception. A need for rapid detection of Candida is made possible by the use of Calcofluor - White (CFW) stain when examined under a fluorescence microscope. The present study was aimed at assessing the efficacy of CFW is compared to Gram stain and periodic acid Schiff (PAS) in detection of Candida in oral precancer and cancer.

Materials and Methods:

The study group consisted of patients with precancer (n=45), cancer (n=45), and control group (n=45). Presence of Candida was confirmed by culture inoculation along with a germ tube and carbohydrate fermentation test. The cytopathological smears were analyzed by papanicolaou - CFW and Gram staining, whereas, tissue sections were stained by PAS and CFW staining.

Results:

Candida albicans was the predominant species identified. A highly significant association of Candida was seen more often in cancer than in precancer. Both in cytology and histopathology Candida detection by CFW was higher. In precancer it was 48.88% in smears and 40% in tissue sections, whereas, in cancer 60% in smears and 55.55% in histopathology.

Conclusion:

Among the various diagnostic tools used in the present study, the use of CFW is seen to be a simple, effective, rapid, and reliable method, both in cytopathology and histopathology.

Urban legends series: oral candidosis

Candida species (spp) are commensal yeast that can only instigate oral infection (oral candidosis - OC) when there is an underlying predisposing condition in the host. We investigated four controversial topics on OC: (i) How can a microbiological determination of OC be made as Candida spp. are commensal yeasts and not all of them form hyphae or pseudohyphae during infection? (ii) Is median rhomboid glossitis (MRG) a manifestation of candidal infection? (iii) Can candidal infection cause palate papillary hyperplasia (PPH)? (iv) What is the best therapeutic treatment for denture-associated erythematous stomatitis (DAES)? Results from extensive literature searches, including a systematic review, suggested the following: (i) the diagnosis of OC merely on the basis of the presence of yeasts is an oversimplification of a complex process. No convincing evidence of a single test or method better able to discriminate the transition from candidal saprophytism to pathogenicity has been reported in the literature; (ii-iii) conclusive evidence of a direct aetiopathogenic relationship between MRG and PPH and candidal infection has not been found; and (iv) only limited evidence is available for any DAES treatment, thus making it impossible to make strong therapeutic recommendations.

The effect of gentian violet on virulent properties of Candida albicans

The aim of this study was to evaluate the effect of gentian violet (GV) on phospholipase activity, proteinase activity and germ tube formation rate of Candida albicans. Both 12 phospholipase-positive and 12 proteinase-positive C. albicans isolates with Pz values <or=0.89 were obtained. A yeast suspension (1-3 x 10(7) cfu/ml) of each isolate was prepared. After a brief exposure (60 min) to sub-therapeutic concentrations (0.5 or 2 microg/ml) of GV, Pz value of phospholipase, Pz value of proteinase and germ tube formation rate were determined. Phospholipase activity, proteinase activity and germ tube formation rate in two groups exposed to GV were significantly lower than those in the group unexposed (P < 0.05). The results of this study indicated that sub-therapeutic concentrations of GV may lead to reduction in phospholipase activity, proteinase activity and germ tube formation, and then may suppress virulence and pathogenicity of C. albicans.

Usefulness of culture test and direct examination for the diagnosis of oral atrophic candidiasis

BACKGROUND

Culture test and direct microscopy, which are currently used in the diagnosis of oral candidiasis, can yield false-negative results.

METHODS

Forty patients with atrophic candidiasis of the tongue were evaluated. The diagnosis was confirmed by a favorable outcome consisting of tongue pain improvement and regeneration of filiform papilla after antifungal treatment in all patients. Specimens were examined by fungal culture and direct microscopy following rapid staining; the usefulness of these procedures for diagnosis was reevaluated retrospectively after treatment.

RESULTS

In the culture test, 30 patients (75.0%) were positive for candidal species, most of which were confirmed to be Candida albicans. Twenty-three (57.5%) were positive for pseudohyphae of fungi on direct examination. Twenty-two (55.0%) were positive and nine (22.5%) were negative for both. With regard to the diagnosis of oral atrophic candidiasis, these examinations revealed false-negative results of 25% in the culture examination and 42.5% in the direct examination.

CONCLUSION

Careful clinical observation of the patient for signs, such as prolonged disease duration, pain on eating, and no benefit from topical steroid treatment, and cytologic examination are important in the diagnosis of this disease.

Candida albicans Adherence to Glass Ionomer Restorative Dental Material

Background and aims

It is believed that adherence of Candida albicans to oral surfaces is a critical event in the coloni-zation and development of oral diseases such as candida-associated denture stomatitis. Although there is considerable infor-mation about the adherence of Candida albicans to buccal epithelial cells and prosthetic materials, there is very little infor-mation available about the adherence of Candida albicans to glass ionomer materials. The purpose of this study was to investigate the degree of Candida albicans adherence to glass ionomer restorative material.

Materials and methods

In this experimental study adherence of Candida albicans strains was studied with and without human whole saliva. First, glass ionomer fragments were prepared; then yeast cells were inoculated and incubated with differ-ent incubation times. After incubation, the fragments were removed from the wells and stained with 0.1% calcofluor white. Adhesion was quantified by counting the total number of cells at 40, 80 and 120 minutes. The analysis of variance and Stu-dent's test were used to assess the significance of differences between the means.

Results

In the absence of saliva, the adherence of Candida albicans showed an increase, reaching a maximum at the end of the experiment (120 minutes). However, in the presence of saliva, the adherence of Candida albicans to glass ionomer significantly decreased.

Conclusion

The presence of human whole saliva is an important factor in the adherence of Candida albicans to glass ion-omer restorative material.

Topical clobetasol in the treatment of atrophic-erosive oral lichen planus: a randomized controlled trial to compare two preparations with different concentrations

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful, mainly in the atrophic and erosive forms. Numerous drugs have been used with dissimilar results, but most treatments are empirical and do not have adequate control groups or correct study designs. However, to date, the most commonly employed and useful agents for the treatment of LP are topical corticosteroids. A randomized, double-blind, placebo-controlled trial has been designed to compare the efficacy and safety of two different formulations of clobetasol, a very potent topical steroid, in the topical management of OLP and to evaluate which gives the longest remission from signs and symptoms. Thirty-five consecutive patients were divided into two groups: the first received clobetasol propionate 0.025% and the second was given clobetasol propionate 0.05%. Both drugs were placed in 4% hydroxyethyl cellulose bioadhesive gel. Anti-mycotic prophylaxis was also added. After the end of therapy, patients received a 2-month follow-up. In all, 14 of the 15 clobetasol 0.025% patients (93%) and 13 of the 15 clobetasol 0.05% patients (87%), had symptoms improvement after 2 months of therapy (P = 0.001 in both groups). Also, 13 of the 15 clobetasol 0.025% patients (87%) and 11 of the 15 clobetasol 0.05% patients (73%) had clinical improvement after 2 months of therapy (P < 0.05 in both groups). No statistical differences were found in comparing the two different formulations. A larger concentration of the active molecules cannot further improve the therapeutic findings or optimize the obtained results in a significant manner.

Phospholipase activity of Candida albicans isolates from patients with denture stomatitis: the influence of chlorhexidine gluconate on phospholipase production

BACKGROUND AND OBJECTIVES

The extracellular phospholipases of Candida albicans are considered to play a significant role in the pathogenesis of human infections. Therefore 23 clinical oral isolates of C. albicans from patients with denture stomatitis and 22 commensal oral isolates obtained from the palatal mucosa of healthy subjects were assayed for phospholipase activity. It is generally accepted that chlorhexidine gluconate is an appropriate adjunct or an alternative to antimycotic therapy in the management of oral candidiasis. However, the intraoral concentrations of this antiseptic fluctuate considerably due to the dynamics of the oral cavity. So the second main objective of this study was to investigate the effect of brief exposure (30 min) to two sub-therapeutic concentrations (0.002% and 0.0012%) of chlorhexidine gluconate on the value of phospholipase production (Pz) of C. albicans.

METHOD

An in vitro phospholipase production was done by plate assay method using an egg yolk-agar medium.

RESULTS

No significant differences were found in the number of C. albicans isolates producing phospholipase between two groups. However, the mean value of Pz produced by the isolates from patients with denture stomatitis was significantly (p<0.05) higher than the commensals. Exposure of the isolates to 0.002% and 0.0012% chlorhexidine led to a significant (p<0.001 and p<0.01, respectively) reduction in the amount of phospholipase.

CONCLUSION

The results of this study imply that sub-therapeutic levels of chlorhexidine may modulate candidal phospholipase activity, thereby suppressing pathogenicity of C. albicans.

Cheilitis as a variation of Candida-associated lesions

OBJECTIVE

Occasionally, the clinical diagnosis of Candida-associated lesion is difficult because of a variety of its clinical manifestations. There have been a few reports on Candida-associated lip lesion except angular cheilitis. In this paper, we investigate the relation of Candida in persistent lesions of the lip.

SUBJECTS AND METHODS

The present study includes consecutive nine patients with persistent erosive lip lesion. For each patient the age at presentation, gender, duration of the disease, other symptoms or signs, complete medical history and prior treatment or medications for the symptom were obtained. Then, mycological examination and the direct cytologic examination were performed.

RESULTS

The reported average duration of the disease was 7 months. Six of nine patients had received prior treatments with topical steroids at the other clinic, which failed to resolve their symptoms. Six of nine patients had a predisposing factor for candidiasis. In the culture examination, Candida albicans were isolated in seven patients (77.8%). Five of nine patients received the direct cytologic examination, and four of them revealed pseudohyphae of fungi. The anti-fungal treatment was miconazol gel 25 mg four times per day, and average duration of the treatment was 2 weeks. The outcome was as follows: complete remission in five, remarkable response in two and no response in two.

CONCLUSION

Our results suggested that one form of the varieties of Candida-associated lesions might be considered in the case of lip lesion with unknown origin that was persistent and ineffective to the topical steroids treatment.

Improved oral hygiene and Candida species colonization level in geriatric patients

OBJECTIVES

This work consists in improving oral hygiene (OH) for elderly dependent people in long-term hospital care, in order to decrease the degree of colonization and the associated risk of developing oral candidiasis. As this population frequently suffers from such colonization and because it is difficult to install and practice OH care, a study protocol was designed at the request of geriatricians. The objective of the present study was to set up a programme of OH, applied by the care staff, and to monitor oral colonization of by Candida spp.

BASIC RESEARCH DESIGN

We compared the levels of hygiene and Candida spp. colonization for a group of 110 long-term patients in geriatric departments at T1, when clinical data were collected and oral mycological samples taken before the OH protocol was applied, and at T2, during the postprotocol phase after 3 months of application, when the clinical data and sample collection were repeated.

RESULTS

During these 3 months 11 patients died. These patients were excluded from the results, which are presented for matched series of the 99 patients still present at T2. Statistical analysis comparing the clinical and biological parameters at T1 and T2 established that there had been an improvement in OH: the 'adequate' level was reached for 72.4% of patients at T2 compared with 41.8% at T1 (P < 0.001) and the 'very inadequate' level was observed for 9.2% at T2 compared with 27.9% at T1 (P < 0.01). A reduction was observed in the number of patients showing the highest degree of C. albicans and C. glabrata colonization (> 50 colony forming units) from 41.9% at T1 to 24.9% at T2 (P < 0.05) and from 56.4% at T1 to 13.0% at T2 (P < 0.05) respectively. The number of patients with candidiasis fell significantly from 43.2% at T1 to 10.2% at T2.

CONCLUSIONS

The OH protocol led to an overall decrease in Candida spp. colonization, a significant reduction in the number of candidiasis and an improvement in the level of oral and denture hygiene but vigilance is still necessary concerning OH care and the initial training of staff in specific care of the mouth.

Diagnosis and management of suspicious lesions of the oral cavity

Oral lesions associated with premalignant changes and malignancy present in diverse ways. This article discusses the clinical characteristics of such lesions enabling clinicians to identify classical features.Additionally, an effort is made to familiarize clinicians with the significance of red and white lesions, especially those having a high index of suspicion for oral cancer, and to alert clinicians when a biopsy is mandatory.

Relationship between Candida infection and immune cellular response in inflammatory hyperplasia

OBJECTIVES

To analyze and quantify the CD8(+) and CD4(+) T-lymphocyte populations in inflammatory hyperplasia and to establish the relationship between the frequency and location of these cells and Candida infection.

METHODS

Samples of inflammatory hyperplasia were stained with PAS for evidence of Candida sp. and were classified in two groups, infected and control, according to the presence or absence of infection. After immunoreaction with specific anti-CD4 and anti-CD8 monoclonal antibodies, the distribution and frequency of the positive cells were analyzed in 41 cases (19 controls without Candida sp. and 22 infected cases). Lymphocytes were quantified in the three consecutive fields where the inflammatory infiltration was concentrated.

RESULTS

There was no relationship between the frequency and location of CD4(+) T cells and Candida sp. infection. The number of CD8(+) cells close to the fungi hyphae as well as the total number of CD8(+) T cells present in inflammatory hyperplasia were higher in the Candida sp. group than in the control noninfected group (P < 0.05).

CONCLUSION

Since the CD8(+) T cells were distributed according to the location of Candida sp. hyphae, and since a higher CD8(+)/total lymphocytes ratio was observed in the infected group, we suggest a role for CD8(+) T cells in the defense against Candida in oral infections associated with inflammatory hyperplasia in immunocompetent individuals.

Oral fungal infections

Candidiasis is the most common oral fungal infection diagnosed in humans. Candidiasis may result from immune system dysfunction or as a result of local or systemic medical treatment. Because oral candidiasis is generally a localized infection, topical treatment methods are the first line of therapy, especially for the pseudomembranous and erythematous variants. Patients with dental prostheses should also be advised to disinfect the prosthesis routinely during the candidal treatment period, because the prosthesis may serve as a source of reinfection. Additionally, patients should be advised that oral hygiene aids, such as toothbrushes and denture brushes, may also be contaminated and should be discarded or disinfected. A disinfecting solution of equal parts of hydrogen peroxide and water may be used. Likewise, 2% chlorhexidine gluconate solution may be used asa disinfecting solution for dental prostheses and oral hygiene aids. Occasionally the clinician encounters a more resistant form of oral candidiasis such as the hyperplastic variant or a variant that does not respond to topical therapy. Appropriate systemic therapy should be employed for the treatment of these infections. Additionally, a biopsy should be undertaken in individuals with the hyperplastic variant of Candida because there is some degree of risk for malignant transformation. Deep fungal infections should be managed in association with appropriate medical specialists to rule out other systemic involvement. The dental health care provider plays an important part in the diagnosis and management of fungal disease, and therefore clinicians should be aware of the presenting signs and symptoms or oral fungal disease.

Diagnosis and Management of Candida and Other Fungal Infections of the Head and Neck

Fungi are common inhabitants of the oral and nasal mucosa, and therefore the differentiation between colonization and pathogenicity in the setting of upper respiratory tract infection symptoms can be difficult. Fungal head and neck infections occur in both immunocompetent and immunocompromised persons, and patients with neutropenia, diabetes mellitus, corticosteroid use, and HIV infection are particularly susceptible to serious and potentially life-threatening infections. Invasive fungal head and neck infections generally require extensive surgical debridement and prolonged systemic antifungal therapy, and frequently carry a poor prognosis when the underlying immunosuppression cannot be corrected. In contrast, noninvasive fungal head and neck infections often respond to short courses of systemic or topical antifungal therapy, or require limited surgical debridement alone.

Prevalence of fluconazole-resistant strains of Candida albicans in otherwise healthy outpatients

BACKGROUND

In contrast to the immunosuppressed patient population, the prevalence of fluconazole-resistant strains of Candida albicans among healthy individuals has not been extensively studied.

METHODS

Candida species were cultured form 50 healthy outpatients with clinical signs of oral candidiasis. Following one week of the recommended fluconazole regimen, post-treatment cultures were obtained. Both pre- and post-treatment yeasts were identified and in vitro susceptibility testing was performed using the NCCLS M-27A method. Strains were further differentiated using established cDNA probes.

RESULTS

Forty-four patients (88%) had positive C.albicans cultures prior to treatment. Antifungal susceptibility testing of these strains demonstrated no in vitro resistance to fluconazole. At post-treatment evaluation, eight patients (18%) had persistent signs of infection and 10 patients (23%) had positive Candida sp. cultures despite no clinical signs of infection. DNA analysis confirmed that the same C. albicans strain was present both in the pre-treatment and the post-treatment cultures.

CONCLUSIONS

Our results showed that the presence of fluconazole-resistant strains of C.albicans does not appear to be prevalent among healthy outpatients furthermore, in vitro antifungal susceptibility testing does not always predict successful therapy in these patients.

A comparison of salivary calprotectin levels in subjects with and without oral candidiasis

OBJECTIVES

The purpose of this study was to compare salivary calprotectin levels in subjects with oral candidiasis to the levels in healthy age- and sex-matched control subjects and to investigate the relationship of salivary calprotectin to intensity of oral candidal carriage and infection and to predisposing factors for candidiasis.

STUDY DESIGN

Using enzyme-linked immunosorbent assay, we measured calprotectin in unstimulated whole saliva collected from 22 subjects with oral candidiasis and in saliva collected from 22 control subjects. Calprotectin levels in the 2 groups were compared by using the Wilcoxon signed rank test. The relationships between calprotectin levels and Candida counts were assessed by using the Spearman rank correlation test. The nonparametric 1-way analysis of variance test was used to study the relationship between calprotectin levels and presence of non-albicans Candida and individual predisposing factors for candidiasis. The Kruskal-Wallis test was used to evaluate the relationship between calprotectin and predisposing factors in subjects grouped by total number of predisposing factors identified.

RESULTS

No relationship was found between calprotectin and individual or total number of predisposing factors. Higher calprotectin levels were found in subjects with candidiasis, and calprotectin concentration positively correlated with intensity of candidal infection.

CONCLUSIONS

These findings suggest that calprotectin production, or release, or both, may be increased in subjects with candidiasis.

Pathology and clinical correlates in oral candidiasis and its variants: a review

Although Candida albicans is well recognised as the major agent of oral candidiasis, it is not clear why several variants such as pseudomembranous (PC), erythematous (EC) and hyperplastic candidiasis (HC) manifest in different individuals, sometimes singly and on other occasions, in combination. The present review focuses on recent histopathologic and immunocytochemical studies as well as the pathogenic attributes of the yeast, in an attempt to address the following queries. (1) Do histopathologic studies of the different variants of candidiasis in immunocompetent and immunocompromised individuals help explain these varying manifestations? (2) Under what circumstances does oral candidiasis manifest as a pseudomembranous rather than an erythematous lesion or vice versa? (3) Are there differences in immunoreactivity in closely adjacent mucosae so that the variable presentation of such lesions reflect differences in the local mucosal immune system? Recent studies of PC, EC and HC offer some insights into the pathogenic mechanisms involved. Histopathologic and immunohistochemical finding in cases of PC and EC in HIV-infected patients and controls appear to be comparable, with a marked reduction or even an absence of CD4+ cells. The latter phenomenon is marked in PC compared with the EC, and explicable in terms of a breakdown of the local immune response in the former, and a hypersensitivity reaction against Candida antigens in the latter. Hyperplastic candidiasis on the other hand could be considered a superficial cellular reaction against the pathogen, which cannot entirely be eradicated by the systemic or local host immune response. The virulent attributes of the fungus, such as the production of extracellular proteinases, do significantly differ within and between species and thereby play a contributory role in the genesis of the clinical variants. Although the available data do give a tantalising glimpse of the contributory mechanisms for the aetiopathology of PC, EC and HC, further research is warranted to elucidate response of the host to this ubiquitous fungal pathogen.

Viral and fungal infections of the oral cavity in immunocompetent patients

Oral lesions are easily visualized and often are signs of systemic diseases. Clinical diagnosis of viral and fungal infections can sometimes be confusing because many lesions will have similar clinical presentations. This article reviews the more common viral- and fungal-associated lesions found in the oral cavity in immunocompetent individuals. Differential diagnoses for the oral lesions are discussed and treatment options are proposed.

Clinical management of selected oral fungal and viral infections during HIV-disease

The purpose of this review is to describe current possibilities of management of selected fungal and viral oral opportunistic infections including oral candidiasis, herpes simplex type 1 and 2-related lesions (HSV1,2), oral hairy leukoplakia (OHL) and oral lesions associated with human papilloma viruses (HPV). Less common diseases such as cytomegalovirus infection or human herpes virus type 8 associated with Kaposi's sarcoma and others are not considered. In a number of instances lifelong therapy or prophylaxis has to be instituted. Antiretroviral combination therapy, also called highly active antiretroviral therapy (HAART), has considerably changed the frequency of oral lesions caused by opportunistic agents. A short description of the antiretroviral agents available including respective side-effects is presented.

Problems and abnormalities found on routine clinical head and neck examination

During the initial examination of a patient, the orthodontist may encounter various findings that will, for the most part, be normal or variants of normal. Most pathological conditions encountered will be derived from structures normally found in the anatomic locations examined. Knowledge of the anatomy and common pathological entities based on location can prove helpful when abnormalities are encountered. This article describes anatomic locations and their contents in and around the oral cavity and discusses pathological processes commonly encountered in these locations. Syndromes involved with various abnormalities also are briefly mentioned. The intent of this article is to give the clinician a working knowledge of commonly occurring pathological entities.

In vitro antifungal resistance of oral Candida albicans strains in non-AIDS patients

Some cases of oral candidosis are refractory to antifungal treatment. This might be related to development of resistant Candida strains, but susceptibility testing is not standardized and not routinely available, and information related to this problem is scarce in non-AIDS patients. In this study, the in vitro antifungal resistance of oral Candida albicans strains was evaluated. The strains were obtained from a cohort of 72 HIV-negative patients with oral yeast carriage and clinical complaint. Laboratory identification revealed C. albicans in 93% of cases. None of these oral C. albicans isolates showed in vitro resistance to polyenes, but they showed varying resistance levels to fluorocytosine and azoles. This study confirms the usefulness of standardizing susceptibility testing so that it could be routinely available and of realizing a mycological diagnosis including an antifungigram when oral candidosis is suspected, whenever antifungal treatment with azoles is planned.

Clinical management of oral and perioral candidosis

Oral candidosis is a diagnosable and treatable mucosal disease that may be complicated by various other local or systemic disease conditions. Dependable diagnosis always should include a combination of clinical signs and symptoms suggestive of candidal disease as well as positive cytologic or direct culture results. The management of candidal infections should be individualized for each patient, with concern for interactions with current medications, immune status, other concurrent mucosal diseases, and exogenous infectious sources. In selecting the appropriate therapeutic agent(s) the clinician should consider patient health factors, location and severity of infection, and the probability of chronicity.

A comparative study of the efficacy of fluconazole and amphotericin B in the treatment of oropharyngeal candidosis in patients undergoing radiotherapy for head and neck tumours

Radiotherapy given during treatment of oral and pharyngeal malignancy is frequently associated with colonization of the oral mucosa by Candida species. Treatment of these infections has included topical and systemic agents. In the present study 73 patients with oropharyngeal candidosis were treated with either amphotericin B (10 mg lozenges, four times daily for 14 days, 36 patients) or fluconazole (50 mg daily for 7 days, 37 patients). The yeasts most frequently isolated were C albicans and C glabrata. Clinical signs and symptoms showed improvement at end of treatment in 72% of patients who received amphotericin B compared with 92% of patients who received fluconazole. Mycological cure at end of treatment was achieved in 31% of the amphotericin B group and 46% of patients who received fluconazole. For both treatments the cure rate was less in denture wearers than in non denture wearers.

Cutaneous congenital candidiasis: a case report

Candida albicans is a frequent pathogen of the female genital tract, especially during pregnancy. Congenital candidiasis can occur as cutaneous or disseminated infection. We report a case of congenital cutaneous candidiasis, which may occur more frequently than is indicated by the literature. This is followed by a discussion of the pathogenesis, clinical presentation, diagnosis, and treatment of this infection.

Relationship between salivary flow rates and Candida albicans counts

Seventy-one persons (48 women, 23 men; mean age, 51.76 years) were evaluated for salivary flow rates and Candida albicans counts. Each person was seen on three different occasions. Samples of unstimulated whole, chewing-stimulated whole, acid-stimulated parotid, and candy-stimulated parotid saliva were collected under standardized conditions. An oral rinse was also obtained and evaluated for Candida albicans counts. Unstimulated and chewing-stimulated whole flow rates were negatively and significantly (p < 0.001) related to the Candida counts. Unstimulated whole saliva significantly (p < 0.05) differed in persons with Candida counts of 0 versus <500 versus < or = 500. Chewing-stimulated saliva was significantly (p < 0.05) different in persons with 0 counts compared with those with a > or = 500 count. Differences in stimulated parotid flow rates were not significant among different levels of Candida counts. The results of this study reveal that whole saliva is a better predictor than parotid saliva in identification of persons with high Candida albicans counts.

A review of oral fungal infections and appropriate therapy

Dental health care providers must recognize oral fungal pathogens that often are markers for early signs of immune deterioration. After accurate identification, appropriate therapy can be initiated. Predisposing factors for development of oral fungal infections, identification of oral fungal infections, treatment options and their relative costs are reviewed.