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Oral Candidosis: Pathophysiology and Best Practice for Diagnosis, Classification, and Successful Management. J Fungi (Basel) 2021; 7:jof7070555. [PMID: 34356934 PMCID: PMC8306613 DOI: 10.3390/jof7070555] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/10/2021] [Accepted: 07/11/2021] [Indexed: 01/12/2023] Open
Abstract
Oral candidosis is the most common fungal infection that frequently occurs in patients debilitated by other diseases or conditions. No candidosis happens without a cause; hence oral candidosis has been branded as a disease of the diseased. Prior research has identified oral candidosis as a mark of systemic diseases, such as hematinic deficiency, diabetes mellitus, leukopenia, HIV/AIDS, malignancies, and carbohydrate-rich diet, drugs, or immunosuppressive conditions. An array of interaction between Candida and the host is dynamic and complex. Candida exhibits multifaceted strategies for growth, proliferation, evasion of host defenses, and survival within the host to induce fungal infection. Oral candidosis presents a variety of clinical forms, including pseudomembranous candidosis, erythematous candidosis, angular cheilitis, median rhomboid glossitis, cheilocandidosis, juxtavermillion candidosis, mucocutaneous candidosis, hyperplastic candidosis, oropharyngeal candidosis, and rare suppurative candidosis. The prognosis is usually favorable, but treatment failure or recurrence is common due to either incorrect diagnosis, missing other pathology, inability to address underlying risk factors, or inaccurate prescription of antifungal agents. In immunocompromised patients, oropharyngeal candidosis can spread to the bloodstream or upper gastrointestinal tract, leading to potentially lethal systemic candidosis. This review therefore describes oral candidosis with regard to its pathophysiology and best practice for diagnosis, practical classification, and successful management.
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Hu L, Zhou P, Zhao W, Hua H, Yan Z. Fluorescence staining vs. routine KOH smear for rapid diagnosis of oral candidiasis—A diagnostic test. Oral Dis 2020; 26:941-947. [PMID: 32011074 DOI: 10.1111/odi.13293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/17/2019] [Accepted: 01/14/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Lijun Hu
- Department of Oral Medicine Peking University School and Hospital of Stomatology National Engineering Laboratory for Digital and Material Technology of Stomatology Beijing China
- Department of Oral Medicine The Affiliated Stomatology Hospital Zhejiang University School of Medicine Key Laboratory of Oral Biomedical Research of Zhejiang Province Zhejiang University School of Stomatology Hangzhou China
| | - Peiru Zhou
- Department of Oral Medicine Peking University School and Hospital of Stomatology National Engineering Laboratory for Digital and Material Technology of Stomatology Beijing China
| | - Weiwei Zhao
- Department of Oral Medicine Peking University School and Hospital of Stomatology National Engineering Laboratory for Digital and Material Technology of Stomatology Beijing China
| | - Hong Hua
- Department of Oral Medicine Peking University School and Hospital of Stomatology National Engineering Laboratory for Digital and Material Technology of Stomatology Beijing China
| | - Zhimin Yan
- Department of Oral Medicine Peking University School and Hospital of Stomatology National Engineering Laboratory for Digital and Material Technology of Stomatology Beijing China
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Candida is a protractive factor of chronic oral ulcers among usual outpatients. JAPANESE DENTAL SCIENCE REVIEW 2018; 54:52-58. [PMID: 29755615 PMCID: PMC5944075 DOI: 10.1016/j.jdsr.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 11/17/2017] [Accepted: 12/09/2017] [Indexed: 11/21/2022] Open
Abstract
Although many oral ulcers have similar clinical appearances, their etiologies can range from reactive to neoplastic to oral manifestations of dermatological diseases. In patients with an HIV infection, fungal diseases may cause ulceration in the oral cavity; however, there have been few studies of oral ulcerative lesions associated with Candida in patients without an HIV infection. Nevertheless, we encountered chronic oral ulcer associated with Candida among our frequent outpatients without an HIV infection. The present article reviews the causes of oral ulcers, focusing on Candida as a protractive factor for chronic oral ulcers, and it is recommended that Candida involvement be considered in diagnosis of a certain chronic oral ulcer, that remains of unknown origin even if some examinations have been performed.
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Nakamura S, Okamoto MR, Yamamoto K, Tsurumoto A, Yoshino Y, Iwabuchi H, Saito I, Maeda N, Nakagawa Y. The Candida species that are important for the development of atrophic glossitis in xerostomia patients. BMC Oral Health 2017; 17:153. [PMID: 29246167 PMCID: PMC5732471 DOI: 10.1186/s12903-017-0449-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 12/07/2017] [Indexed: 12/19/2022] Open
Abstract
Background The purpose of this study was to clarify the species of Candida that are important for the development of atrophic glossitis in xerostomia patients. Methods A total of 231 patients with subjective dry mouth were enrolled in the present study. Logistic regression analysis was performed to clarify the contribution of each Candida species and other variables to the development of atrophic glossitis. The dependent variable was the absence/presence of atrophic glossitis. The Candida colony-forming units (CFU) of C. albicans, C. glabrata, C. tropicalis, and C. krusei, as well as age, gender, resting (RSFR) and stimulated (SSFR) whole salivary flow rate, and denture-wearing status, were treated as explanatory variables. Results Logistic regression analysis showed that two factors were closely associated with the presence of atrophic glossitis: an increase in C. albicans CFU and a decrease in the SSFR. Conclusions C. albicans, but not non-albicans Candida, was associated with atrophic glossitis in xerostomia patients who had no systemic predisposing factors, indicating that C. albicans remains a treatment target for Candida-related atrophic glossitis.
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Affiliation(s)
- Sachika Nakamura
- Department of Clinical Pathophysiology., Tsurumi University School of Dental Medicine, Tsurumi University Dental Hospital, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, 230-8501, Japan.,Department of Oral Microbiology, Tsurumi University, School of Dental Medicine, Yokohama, Japan
| | - Mariko R Okamoto
- Department of Clinical Pathophysiology., Tsurumi University School of Dental Medicine, Tsurumi University Dental Hospital, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, 230-8501, Japan.,Department of Oral Microbiology, Tsurumi University, School of Dental Medicine, Yokohama, Japan.,Kobayashi Dental Clinic, Niigata, Japan
| | - Ken Yamamoto
- Department of Clinical Pathophysiology., Tsurumi University School of Dental Medicine, Tsurumi University Dental Hospital, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, 230-8501, Japan.,Community Dentistry, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Akihisa Tsurumoto
- Community Dentistry, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Yoko Yoshino
- Department of Clinical Pathophysiology., Tsurumi University School of Dental Medicine, Tsurumi University Dental Hospital, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, 230-8501, Japan.,Department of Nutrition and Dietetics, Sagami Women's University, Sagamihara, Japan
| | - Hiroshi Iwabuchi
- Department of Dentomaxillofacial Diagnosis and Treatment, Division of Oral and Maxillofacial Surgery, Graduate School of Kanagawa Dental University, Yokosuka, Japan
| | - Ichiro Saito
- Department of Clinical Pathophysiology., Tsurumi University School of Dental Medicine, Tsurumi University Dental Hospital, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, 230-8501, Japan.,Department of Pathology, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Nobuko Maeda
- Department of Oral Microbiology, Tsurumi University, School of Dental Medicine, Yokohama, Japan
| | - Yoichi Nakagawa
- Department of Clinical Pathophysiology., Tsurumi University School of Dental Medicine, Tsurumi University Dental Hospital, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, 230-8501, Japan.
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Katiraee F, Teifoori F, Soltani M. Emergence of azole-resistant Candida species in AIDS patients with oropharyngeal candidiasis in Iran. Curr Med Mycol 2015; 1:11-16. [PMID: 28680991 PMCID: PMC5490324 DOI: 10.18869/acadpub.cmm.1.3.11] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose: Oropharyngeal candidiasis (OPC) and antifungal drug resistance are major health concerns in patients with human immunodeficiency virus (HIV). The increased reports of antifungal resistance and expanding drug therapy options prompted the determination of antifungal susceptibility profile. The present study was performed to determine the antifungal susceptibility of Candida species isolated from AIDS patients with OPC in Iran. Materials and Methods: In total, 100 Candida isolates from the oral cavity of patients with OPC (TCD4 < 200 cells/μL) were obtained and cultured on CHROMagar and Sabouraud’s dextrose agar. All isolates were identified according to the assimilation profile, colony color and other conventional methods. Broth microdilution of antifungal drugs was carried out, according to the methods described in M27-S4 and M44-A guidelines by the Clinical and Laboratory Standards Institute (CLSI). Results: Among 60 Candida albicans (C. albicans) strains, 56.7% were resistant to fluconazole, while 38.3% were resistant to ketoconazole and clotrimazole. The resistance of C. albicans isolates against polyene antifungals including amphotericin B was scarce (1.7%). Based on the results, 52.2% of C.glabrata strains were resistant to fluconazole, while 47.8% and 30.4% of these isolates were resistant to ketoconazole and clotrimazole, respectively. All Candida isolates were susceptible to nystatin and caspofungin. Conclusion: Based on the findings, it can be concluded that screening of resistant Candida isolates by disk diffusion or broth dilution method is essential for the surveillance and prevention of antifungal resistance in patient management. Although nystatin is widely used in clinical practice for HIV patients in Iran, no evidence of enhanced resistance against this agent was found; on the other hand, resistance to azole antifungals, particularly fluconazole, increased. Considering the lack of resistance to caspofungin, administration of this agent is suggested for the treatment of OPC in AIDS patients.
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Affiliation(s)
- F Katiraee
- Department of Pathobiology, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran
| | - F Teifoori
- Department of Immunology, Microbiology and Parasitology, Faculty of Pharmacy and laboratory of Parasitology and Allergy, Lascaray Research Center, University of the Basque Country, Vitoria, Spain
| | - M Soltani
- Mycology Research Center, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
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Coronado-Castellote L, Jiménez-Soriano Y. Clinical and microbiological diagnosis of oral candidiasis. J Clin Exp Dent 2013; 5:e279-86. [PMID: 24455095 PMCID: PMC3892259 DOI: 10.4317/jced.51242] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 09/26/2013] [Indexed: 12/23/2022] Open
Abstract
Introduction: Candidiasis or oral candidiasis is the most frequent mucocutaneous mycosis of the oral cavity. It is produced by the genus Candida, which is found in the oral cavity of 53% of the general population as a common commensal organism. One hundred and fifty species have been isolated in the oral cavity, and 80% of the isolates correspond to Candida albicans, which can colonize the oral cavity alone or in combination with other species. Transformation from commensal organism to pathogen depends on the intervention of different predisposing factors that modify the microenvironment of the oral cavity and favor the appearance of opportunistic infection.
The present study offers a literature review on the diagnosis of oral candidiasis, with the purpose of establishing when complementary microbiological techniques for the diagnosis of oral candidiasis should be used, and which techniques are most commonly employed in routine clinical practice in order to establish a definitive diagnosis.
Materials and methods: A Medline-PubMed, Scopus and Cochrane search was made covering the last 10 years.
Results: The diagnosis of oral candidiasis is fundamentally clinical. Microbiological techniques are used when the clinical diagnosis needs to be confirmed, for establishing a differential diagnosis with other diseases, and in cases characterized by resistance to antifungal drugs. Biopsies in turn are indicated in patients with hyperplastic candidiasis. Staining (10% KOH) and culture (Sabouraud dextrose agar) are the methods most commonly used for diagnosing primary candidiasis. Identification of the individual species of Candida is usually carried out with CHROMagar Candida®. For the diagnosis of invasive candidiasis, and in cases requiring differentiation between C. albicans and C. dubliniensis, use is made of immunological and genetic techniques such as ELISA and PCR.
Key words:Clinical, oral candidiasis, microbiology.
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Affiliation(s)
- Laura Coronado-Castellote
- Dentistry. Master of Oral Medicine and Oral Surgery. Faculty of Medicine and Dentistry. University of Valencia. Spain
| | - Yolanda Jiménez-Soriano
- Associate Professor of the Department of Stomatology. Faculty of Medicine and Dentistry. University of Valencia. Spain
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Kimori H, Yamamoto K, Yamachika S, Tsurumoto A, Kamikawa Y, Sasao M, Morito M, Saito I, Ohshima T, Maeda N, Nakagawa Y. Factors associated with the presence of atrophic tongue in patients with dry mouth. Gerodontology 2013; 32:13-7. [PMID: 23718267 DOI: 10.1111/ger.12045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to identify factors associated with atrophic tongue in patients with dry mouth. METHODS Discriminant analysis was performed in 1265 patients with dry mouth to identify factors that might influence the risk of developing atrophic tongue. The dependent variable was the presence of atrophic tongue, while patient age, resting saliva flow rate, stimulated saliva flow rate and Candida colony-forming units (CFU) were used as the independent variables. RESULTS The standardised linear discriminant coefficients showed that Candida CFU, stimulated saliva flow rate and age were significantly associated with the presence of atrophic tongue. The following linear discriminant function was obtained: z = 0.024 × age - 0.63 × (resting saliva flow rate) - 0.81 × (stimulated saliva flow rate) + 0.002 × Candida CFU - 0.611. CONCLUSION High Candida CFU, low stimulated saliva flow rate and advanced age were identified as closely associated factors for the risk of development of atrophic tongue.
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Affiliation(s)
- Hisato Kimori
- Department of Clinical Pathophysiology, Tsurumi University Dental Hospital, Yokohama, Japan; Department of Geriatric Dentistry, Tsurumi University School of Dental Medicine, Yokohama, Japan
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Picciani BLS, Michalski-Santos B, Carneiro S, Sampaio AL, Avelleira JCR, Azulay DR, Pinto JMN, Dias EP. Oral candidiasis in patients with psoriasis: correlation of oral examination and cytopathological evaluation with psoriasis disease severity and treatment. J Am Acad Dermatol 2013; 68:986-91. [PMID: 23384796 DOI: 10.1016/j.jaad.2012.11.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 10/28/2012] [Accepted: 11/08/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infections are known to trigger and exacerbate psoriasis. Although oral candidiasis is often clinically diagnosed, it is not always confirmed by laboratory tests such as oral cytopathology. OBJECTIVES The aims of this study were to determine the prevalence of oral candidiasis in patients with psoriasis through clinical and cytopathological diagnosis and to investigate the association between oral candidiasis and psoriasis with regards to the severity of the clinical presentation and the type of treatment for psoriasis. METHODS A total of 140 patients with psoriasis and 140 healthy control subjects received an oral examination. Scrapings of the tongue were also obtained for a cytopathological examination. RESULTS The oral examination and the results of the cytopathological smear revealed 37 (26%) cases of candidiasis in the patients with psoriasis and no cases of candidiasis in the healthy control subjects. There was no correlation between the type of psoriasis treatment and the presence of oral candidiasis (P = .616). There was a statistically significant association (P = .033) between the clinical severity of psoriasis and the presence of Candida. LIMITATIONS This study was limited by the small number of subjects and the lack of follow-up to determine the development of psoriasis after treatment for oral candidiasis. CONCLUSIONS The presence of oral candidiasis is higher in patients with psoriasis and it is associated with disease severity. This increased presence of oral candidiasis was apparent despite any type of treatment for the psoriasis. Cytopathology to rule out oral candidiasis should be used in the routine medical workup of patients with psoriasis.
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Manfredi M, Polonelli L, Aguirre-Urizar JM, Carrozzo M, McCullough MJ. Urban legends series: oral candidosis. Oral Dis 2012; 19:245-61. [PMID: 22998462 DOI: 10.1111/odi.12013] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 07/24/2012] [Accepted: 07/24/2012] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- M Manfredi
- Oral Medicine, Pathology and Laser-assisted Surgery Unit, University of Parma, Parma, Italy
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Okamoto MR, Kamoi M, Yamachika S, Tsurumoto A, Imamura T, Yamamoto K, Kadomatsu S, Saito I, Maeda N, Nakagawa Y. Efficacy of Fungiflora Y staining for the diagnosis of oral erythematous candidiasis. Gerodontology 2012; 30:220-5. [PMID: 22582792 DOI: 10.1111/j.1741-2358.2012.00668.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the efficacy of Fungiflora Y staining (fluorescent stain) for the diagnosis of erythematous candidiasis. SUBJECTS AND METHODS This study enrolled 48 patients who were diagnosed with erythematous candidiasis and who underwent fungal culture and microscopic examination of a smear specimen stained with CytoQuick (modification of the Giemsa stain) and Fungiflora Y. Fungiflora Y staining was observed using a portable fluorescent microscope (CyScope(®)). The sensitivity, specificity and positive and negative predictive values were calculated using fungal culture as the gold standard test. Accuracy was calculated, and the difference between the CytoQuick and Fungiflora Y groups was examined using contingency tables and the chi-square test. RESULTS The sensitivity and specificity of the CytoQuick stain was 0.51 and 0.91, respectively; the positive predictive value was 0.95, and the negative predictive value was 0.36. The sensitivity and specificity of the Fungiflora Y stain was 0.84 and 1.0, respectively; the positive predictive value was 1.00, and the negative predictive value was 0.65. The accuracy of Fungiflora Y (0.88) was superior to that of CytoQuick (0.60) (p = 0.0052). CONCLUSIONS Microscopic examinations of smear specimens using a combination of Fungiflora Y staining and the CyScope(®) portable fluorescent microscope was found to be useful for the diagnosis of oral erythematous candidiasis.
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Affiliation(s)
- Mariko R Okamoto
- Department of Clinical Pathophysiology, Tsurumi University School of Dental Medicine, Tsurumi-ku, Yokohama, Japan
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Nicorandil-induced tongue ulceration with or without fungal infection. Odontology 2011; 100:100-3. [DOI: 10.1007/s10266-011-0015-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 12/12/2010] [Indexed: 10/18/2022]
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Abstract
Salivary diagnostics is a dynamic and emerging field utilizing nanotechnology and molecular diagnostics to aid in the diagnosis of oral and systemic diseases. In this article the author critically reviews the latest advances using oral biomarkers for disease detection. The use of oral fluids is broadening perspectives in clinical diagnosis, disease monitoring, and decision making for patient care. Important elements determining the future possibilities and challenges in this field are also discussed.
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Affiliation(s)
- Daniel Malamud
- Department of Basic Sciences, New York University College of Dentistry, New York, NY 10010, USA.
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Anibal PC, de Cássia Orlandi Sardi J, Peixoto ITA, de Carvalho Moraes JJ, Höfling JF. Conventional and alternative antifungal therapies to oral candidiasis. Braz J Microbiol 2010; 41:824-31. [PMID: 24031562 PMCID: PMC3769763 DOI: 10.1590/s1517-83822010000400001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 04/26/2010] [Indexed: 06/22/2024] Open
Abstract
Candida-associated denture stomatitis is the most common form of oral candidal infection, with Candida albicans being the principal etiological agent. Candida adheres directly or via an intermediary layer of plaque-forming bacteria to denture acrylic. Despite antifungal therapy to treat denture stomatitis, infection is reestablished soon after the treatment ceases. In addition, many predisposing factors have been identified as important in the development of oral candidiasis, including malnourishment, common endocrine disorders, such as diabetis mellitus, antibacterial drug therapy, corticosteroids, radiotherapy and other immunocompromised conditions, such as acquired immunodeficiency syndrome (AIDS). These often results in increased tolerance to the most commonly used antifungals. So this review suggests new therapies to oral candidiasis.
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Affiliation(s)
- Paula Cristina Anibal
- Departamento de Diagnóstico Oral, Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas , Piracicaba, SP , Brasil
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Oropharyngeal candidiasis and oral yeast colonization in Iranian Human Immunodeficiency Virus positive patients. J Mycol Med 2010. [DOI: 10.1016/j.mycmed.2009.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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