Oral candidiasis

1. Oral Candidiasis - Investigations & Management Kingshuk Mazumder Final year BDS

2. Contents Introduction Etiology Classification Investigations Management

3. Introduction Oral candidiasis is the most prevalent opportunistic infection affecting the oral mucosa, caused by the yeast, Candida albicans .

4. Etiology Local predisposing factors for candidiasis General predisposing factors Denture wearing Smoking Atopic constitution Inhalation steroids Topical steroids Hyperkeratosis Imbalance of oral microflora Quality and quantity of saliva Immunosuppressive diseases Immunosuppressive drugs Chemotherapy Endocrine disorders Hematinic deficiencies

5. Classification Accordingly, candidiasis may be classified into: Acute Chronic Pseudomembranous Erythematous Plaque like Nodular Candida associated lesion: Denture stomatitis, angular chielitis

6. Investigations Investigation of candidiasis, is by isolation of Candida from oral samples, by- Smear: Smear from the affected area, which compromises of the epithelial cells, creates opportunities for detection of yeasts. The obtained material is fixed in isopropyl alcohol, and air dried, and then stained with PAS. The detection of yeast, indicates infection. Swab: Taken by rubbing cotton tipped swabs, over the lesional tissue.

7. Investigations ( contd …) 3. Imprint Culture: Sterile plastic foam pads dipped into Sabouraud (Sab) broth, is placed over a lesion for 60 seconds. Pad is pressed on Sab agar plate, and incubated. 4. Impression culture: Maxillary and mandibular alginate impressions; casting in agar; fortified with Sab broth; incubation.

8. Investigations ( Contd …) 5. Salivary culture: Patient expectorates 2ml saliva into sterile container; vibration; followed by culture on Sab agar by spiral plating; followed by counting. 6. Oral Rinse: Subject rinses for 60 seconds with Phosphate buffered saline (PBS), at 7.2 pH, 0.1 M, and returns it to the original container. This is concentrated by centrifugation, cultured, and counted as in previous methods.

9. Management Management of candidiasis is on the basis of identifying the predisposing factor. Most common anti-fungal drugs are polyenes or azoles. Polyenes are not absorbed from the gastro-intestinal tract, and are not associated with developing resistance.

10. Management by topical agents: DRUG FORM DOSAGE Amphotericin B Lozenge, 10 mg Slowly dissolved in the mouth, 3-4 times/day after meals, for 2 weeks Nystatin Cream Apply to affected areas 3-4 times/day Clotrimazole Cream Apply to the affected areas, 2-3 times/day, for 3 days

11. DRUG FORM DOSAGE Ketoconazole Tablets 200-400mg tablets, taken once or twice daily with food, for 2 weeks. Fluconazole Capsules 50-100 mg capsules, once daily, for 2-3 weeks. Management by Systemic drugs:

12. Management ( contd …) Type III d enture stomatitis may be treated with surgical excision, if necessary, to eradicate micro-organisms seated in the deep fissures of granulation tissue. Systemic azoles may be used for deeply seated primary candidiasis, such as chronic hyperplastic candidiasis, denture stomatitis, and median rhomboid glossitis . Development of resistance is common for Fluconazole, in HIV patients. Ketoconazole and Itraconazole , are the suggested anti- biotics .

13. Management of candidiasis in HIV Patients In general, antiretroviral therapy is recommended for any patient with a history of AIDS defining illness. Available retroviral drugs are classified into: Fusion Inhibitors Nucleoside Reverse Transcriptase Inhibitors ( Eg : Abacavir , Didanosine ) Non-Nucleoside Reverse Transcriptase Inhibitors ( Eg : Delavirdine , Efavirenz , Nevirapine ) Protease Inhibitors ( Eg : Amprenavir , atazanavir )

14. The treatment of HIV requires HAART (Highly active anti-retroviral therapy) combination therapy, like: 1 NNRTI + 2NRTIs 1 or 2 PIs + 2 NRTIs 3 NRTIs In addition to the HAART therapy for HIV management, the patient is prescribed systemic azoles for the treatment of oral candidiasis, like Fluconazole tablets or Ketoconazole capsules. In case of resistance to the above, itraconazole and miconazole are the suggested alternatives. The azoles are also used in the treatment of secondary oral candidiasis, associated with the systemic predisposing factors, in systemic candidiasis.

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