Oral candidiasis

• Oral candidiasis:

  • Candida is a fungus that is a normal commensal flora of the human GI tract
  • If mucosal barriers are disrupted or the hosts immune defence is lowered the fungus can cause candidiasis infection
  • Most common species of candida that causes infections is candida albicans
• Risk factors:

  • Infancy or older age - immature or weakened immune system
  • Immunocompromise - HIV/AIDs, diabetes, haematological cancers
  • Dry mouth (xerostomia) - saliva has antimicrobial proteins to prevent candidal overgrowth
  • Local trauma
  • Poor dental hygiene
  • Dentures - candida adheres to acrylic, decreased saliva slow under dentures, local trauma
  • Medications - broad spectrum antibiotics, corticosteroids, chemo
  • Smoking - especially median rhomboid glossitis
  • Poor diet - affects oral pH
  • Nutritional deficiency - vitamin B, iron (iron dependent enzymes have antifungal effects)
• Acute pseudomembranous candidiasis (oral thrush)

  • Patches of curd like, white or yellowish plaques in the mouth that can be easily removed revealing underlying red raw base
  • May have altered taste, some may have burning or itching sensation
  • Most common in - neonates, elderly, immunocompromised (including taking broad spectrum antibiotics) and xerostomia
• Acute erythematous candidiasis (acute atrophic candidiasis):

  • Sore red shiny patches on palate and tongue
  • Filiform papillae of tongue disappear so looks flat and shiny
  • Commonly occurs secondary to antibiotic treatment, but can happen with any of the risk factors
• Chronic atrophic candidiasis (denture stomatitis):

  • Common in patients with dentures
  • Not usually any symptoms but on examination oral mucosa in contact with dentures is red and swollen
• Angular cheilitis:

  • inflammatory condition affecting corners of mouth causing painful red fissures, usually bilateral
  • Candida infection is a cause but there are many other causes - bacterial infection dry chapped lips, nutritional deficiency (iron, B12), systemic illness e.g. IBD
  • When caused by candida, tends to be in older people, immunocompromised people, people with anaemia or vitamin B12 deficiency
• Chronic hyperplastic candidiasis (plaque like candidiasis):

  • Type of oral leukoplakia (white patch) - persistent nodules or plaques that aren't easily removed because the candida hyphae invade into deeper epithelial levels
  • Usually affects smokers
  • Premalignant condition and if not treated can result in dysplasia and malignant
  • Urgent referral to dentist due to risk of malignancy - may require biopsy, monitoring or surgical resection
• Median rhomboid glossitis:

  • Diamond shaped inflammation at back of tongue
  • Red demarcated area of papillary atrophy
  • Usually seen in - men, smokers, corticosteroid inhalers, diabetics
• Diagnosis of candidiasis is clinical - swabs not usually helpful as candidal organisms are normal commensals
• General management:

  • In otherwise healthy people it may be the first presentation of an undiagnosed risk factor e.g. diabetes, B12 or iron deficiency, identify underlying cause and manage
  • Lifestyle advice - stop smoking, good dental hygiene, review inhaled steroid technique, how to care for dentures and dentist to review fitting
• Mild localised infection:

  • Topical antifungal for 14 days
  • 1st line = miconazole (interacts with statins, warfarin and gliclazide so use nystatin instead)
  • 2nd line = nystatin suspension
• If topical treatment ineffective/infection extensive/severe or patient significantly immunocompromised:

  • Oral fluconazole for at least 14 days
  • Get specialist advice/refer to oral surgeon
• If infection doesn't resolve with initial treatment:

  • If on topical treatment - extend course or switch to nystatin (if miconazole tried first) or to oral fluconazole
  • If not resolved following fluconazole consider:
  • Extending course for a further 7 days
  • Swabbing to identify causative organism
  • Seeking specialist advice or referring to dermatologist/oral surgeon
• Also consider referral or seeking advice if:

  • Recurrent episodes of oral candidiasis
  • Patient has breakthrough candidal infection while receiving preventative treatment (can indicate candidal resistance)
  • Doubt about diagnosis
• Oral candidiasis can cause:

  • Chronic pain and/or discomfort
  • Impaired speech
  • Impaired eating - limiting oral intake
• Complications in severely immunocompromised patients:

  • Oesophageal candidiasis - dysphagia and/or odynophagia
  • Infection can spread through the upper GI tract or blood leading to severe systemic/invasive candidiasis
  • Candidemia = presence of candida species in the blood - most common manifestation of invasive candidiasis
  • Invasive candidiasis is a serious infection that has a mortality rate of up to 80%