FUNGAL INFECTIONS

• The fungal infections of the oral mucosa most frequently occurred due to species of Candida.

• Candida is present as acommensal organism in the mouth of up to 40% of subjects with clinically normal mouths, the number of organisms in the saliva of the carrier being increased with pregnancy, tobacco smoking and with the wearing of dentures.

• Candida is also present as acommensal organism in throat ,lung, bowel and vagina.

• The primary oral reservoir for the organism in carriers in the dorsum of the tongue .

• Isolation of the Candida from the mouth of an adult is not confirmatory evidence of infection and must be considered together with the clinical findings .

• The histological sections must show the hyphae but not spores alone to confirm the diagnosis.

• both general and local predisposing factors are important in the pathogenesis of oral Candida infections for example; debilitated patients , such as those receiving antibiotic, steroid or cytotoxic therapy are particularly susceptible to Candida infections, with local factors such as tobacco smoking ,trauma and xerostomia.

• Non specific and specific factors are involved in protection of the oral mucosa from candidal infection.

• The tissue changes during candidiosis may be due to a direct effect of the toxin on the tissues, a delayed hypersensitivity reaction or enzymatic breakdown of the infected epithelium.

Factors predisposing to oral candidal infection.

*Local factors: • Mucosal traumas• Denture wearing• Denture hygiene• Tobacco smoking

*Age:• Extremes of age ; neonates ,infants, old age

*Drugs:• Broad –spectrum antibiotics • Steroids, Local\ systemic.• Immunosuppressant

*Xerostomia• Drugs, radiotherapy• Sjogren syndrome

*Systemic disease• Iron deficiency• Megablastic anemia• Acute leukemia• Diabetes mellitus• H.I.V infection.• Immunodeficiency status

classification of oral and perioral candidiosis

Candidiasis confined to the oral mucosa

Oral manifestations of generalized candidiosis

Chronic mucoutanous candidiosis (HIV infection)

a-Acute

*Acute psedomembraneous candidiosis (thrush)

*Acute atrophic erythematous candidiosis

b- Chronic

*Chronic atrophic candidiosis (denture stomatitis)

*Candidas associated angular cheilitis

*Chronic hyperplastic canddosis(candidal leukoplakia

• In addition,candidiasis may be found in association with other mucosal lesions, for example, black hairy tongue but a causal relationship has not been fully established.

Acute psedomembraneous candidosis(thrush)

• Generally associated with local disturbance or systemic illness

• Thrush occurs in up to 5%of new born infants, which is probably associated with immature antimicrobial defences,also its seen in about 10%of elderly debilitated patient .

• The disease presents clinically as a thick white coating( the psedomembrane)on the effected mucosa, which can be wiped away to leave a red,rawand often bleeding base.

• Lesions may occurs on any mucosal surface of the mouth and vary in size from small patches to confluent lesions covering a wide area.

Oral thrush

Acute atrophic (erythematous) candidiosis.

• Seen must commonly on the dorsum of the tongue in patients undergoing prolonged corticosteroid or antibiotic therapy ,but it may develop after only a few days of topical application of antibiotic.

• It present as a red and often painful area of oral mucosa which resembles thrush without the overlying psedomembrane.

Chronic atrophic candidosis ( denture

stomatitis)• This is common and usually symptomless condition has been

found in about 50% of denture wearer ,more frequently in women than in man.

• it is regarded as being a secondary candidal infection of tissue modificated by the continual wearing of often ill fitting dentures and is associated with poor denture hygiene.

• The condition is characterized clinically by chronic erythema and oedema of the mucosa directly covered by the denture.

• The palate is usually affected but it is very unusual to see lesions related to lower dentures. The condition may also occur under orthodontic appliances.

denture stomatitis

Clinically ,3 patterns of inflammations can be identified;

• 1- pin - point of erythema – localized inflammation.

• 2- diffuse area of erythema –generalized inflammation.

• 3- erythema associated with a granular or multinodular mucosal surface ,chronic inflammatory papillary hyperplasia.

Overgrowth of the Candida:• The confined space between the mucosa

and the upper denture.

• Inadequate cleaning of the fitting surface

• Wearing the denture throughout the night.

• High carbohydrate diet.

• The irregularities of the fitting surface of the denture.

CANDIDA ASSOCIATED AND OTHER FORMS OF ANGULAR

CHEILITIS.

• Angular cheilitis in a multifactorial disease of infectious origin, seen in about 30% of patients with denture stomatitis.

• Clinically ,angular cheilitis is characterized by soreness,erythema and fissuring at the corners of the mouth.

• Deep folds of skin at the angels of the mouth

• Loss of occlusal height in old age

• Continual wetting by saliva

• Nutritional deficiencies iron folic acid B12 are predisposing factors

ANGULAR CHEILITIS.

Chronic hyperplastic candidosis.

• Commonly referred to as candidal leukoplakia, presents clinically as a persistent white patch on the oral mucosa which is indistinguishable from leukoplakia.

• The lesions present as dense ,opaque white patches of irregular thickness with a rough or nodular surface.

• They cannot be removed by scraping but fragments may be detached and identification of hyphae in smears of such material assists in diagnosis.

• In some cases areas of erythematous mucosa are present within the plaque producing a speckled leukoplakia.

• Lesions are most frequently on the buccal mucosa adjacent to the commeasure of lips and present as roughly triangular, often bilateral white plaques, they are often associated with angular cheilitis. Less frequently, the palate or tongue may be involved.

• in many patients there is a strong association with local factors, such as tobacco smoking, denture wearing and occlusal friction.

• Chronic hyperplastic candidosis is considered to be a premalignant lesion and epithelial dysplasia is seen in about 50% of cases it is not been conclusively shown whether chronic hyperplastic candidosis is primarily leukoplakia with a secondary candidal infection or whether its primarily a chronic candidal infection which in time leads to epithelial hyperplasia and acanthosis.

Chronic mucocutanous candidosis

• This is a rare group of disorders characterized by persistent superficial candidal infections of mucosa, nails and skin. the oral mucosa being involved in almost all cases.

• Oral lesions resemble those seen in chronic hyperplastic candidosis and may involve any part of the mucosa

Subgroup OnsetInheritanceFeatures

Familial CMCEarly First 5 years

Autosomal recessive

mainly oral; skin mild

Diffuse CMCEarly First 5 years

Sporadic\Autosomal recessive

severe skin and oral lesions decrease immunity) candida granulomas

Candidosis endocrinopathy syndrome

Early 2nd decade

Autosomal recessive\sporadic

mild\moderate oral and skin lesionshypoparathyrodismAddison's disease,D.M

Late onset CMClatesporadicmild skin and oral lesionsthymoma

CMC associated with primary immunodeficiencies

Earlysporadic and hereditary types

oral and skin, variable involvement.

Oral manifestation of deep visceral mycoses

• Oral lesions are relatively uncommon presenting most frequently as non-specific ulceration or as nodular granulomatous lesion.