Fungal Infections

Question 1

General predisposing factors to opportunistic infection?

Answer 1

1) Broad-spectrum Antibiotics

2) Corticosteroids (Immunomodulators)

3) Cytotoxics

4) Poorly Controlled Diabetes Mellitus

5) Xerostomia

6) Nutritional Deficiencies

7) Immunosuppression (e.g. extremes of age or HIV)

8) Haematological

Question 2

Local predisposing factors to opportunistic infection?

Answer 2

1) Trauma (e.g. ill-fitting prostheses)

2) Tobacco Smoking

3) Reduced Salivary Flow

4) Carbohydrate-rich Diet
-> Increased Candida adherence to epithelial cells

Question 3

2 acute forms of fungal infection?

Answer 3

Pseudomembranous candidosis
Erythematous candidosis

Question 4

3 chronic forms of candidosis?

Answer 4

Hyperplastic
Erythematous (denture stomatitis)

Question 5

Chronic secondary forms of fungal infection?

Answer 5

Median rhomboid glossitis
Angular cheilitis
Chronic mucocutaneous candidosis

Question 6

Clinical presentation of thrush?

Answer 6

Detachable confluent-white or yellow patches (milk curds) on oral mucosa (often palate)

Wiped away to leave erythematous, bleeding base

Often asymptomatic

Question 7

Histology of white plaques?

Answer 7

Desquamated epithelial cells
Necrotic material
Fibrin
Fungal hyphae

Question 8

Risk factors of thrush?

Answer 8

Immunocompromised pt (extremes of age, poorly controlled diabetes, malignancy, HIV, leukaemia or immunosuppressant drug users)

Question 9

Thrush is often associated with…

Answer 9

Angular cheilitis
Oesophageal candidosis (particularly in HIV pts) -> odynophagia, dysphagia & chest pain

Question 10

Management of thrush?

Answer 10

Improve OH

Identify & treat systemic predisposing factor (e.g. immunosuppression, deficiencies, diabetes etc)

Live active yoghurt (encourages return to normal microflora)

Topical agents:
- CHX m/w (antibacterial & antifungal)
- Nystatin suspension
- Miconazole oral gel (avoid with warfarin)

Question 11

Clinical presentation of acute erythematous candidosis?

Answer 11

Painful erythematous patches

Commonly on dorsum of tongue & palate

Question 12

What is acute erythematous candidosis associated with?

Answer 12

LT broad-spectrum antibiotic use (antibiotic sore mouth)

LT corticosteroid use

HIV

Question 13

Clinical presentation of chronic hyperplastic candidosis?

Answer 13

White-erythematous raised lesions which do not rub off

Usually asymptomatic & found bilaterally on buccal mucosa (towards commissures)

Nodular/speckled = more prone to malignant change OR homogenous plaque-like

Question 14

What is CHC associated with?

Answer 14

Middle-aged male smokers

Question 15

What is the risk associated with CHC?

Answer 15

Malignant transformation to OSCC

If left untreated, 5-10% show dysplasia & may transform to OSCC

Angular cheilitis

Question 16

How to manage CHC?

Answer 16

Biopsy (as it is a premalignant lesion)

FBC (vitamin, iron, folate, glucose levels) & thyroid tests

Remove predisposing factors (e.g. smoking)

Topical antifungals not effective => 2-4+ weeks oral (systemic) fluconazole

Question 17

What is denture stomatitis (chronic erythematous candidosis)?

Answer 17

Chronic erythema of mucosa below fit surface of acrylic upper denture or ortho appliance

Question 18

Aetiology of denture stomatitis?

Answer 18

Denture or appliance fit => saliva excluded from supporting mucosa & commensal candida overgrowth occurs

Question 19

Clinical presentation of denture stomatitis?

Answer 19

Marked erythema of palatal mucosa with margins corresponding to appliance

‘Relief areas’ of denture may have underlying spongy granular change

Usually asymptomatic or angular cheiiltis present

Question 20

What is denture stomatitis associated with?

Answer 20

Poor OH
Poor denture design (non-hygienic design OR poorly fitting denture => trauma)

Question 21

Newton’s classification of denture stomatitis

Answer 21

Type
1 = Pin-point hyperaemia
2 = Diffuse erythema limited to fit surface of denture
3 = Nodular appearance of palatal mucosa

Question 22

Management of denture stomatitis?

Answer 22

Improve denture cleaning:
- Regular cleaning instruction +/- antiseptic soak (e.g. CHX)
- Eliminate tissue trauma (tissue conditioners)
- Improved design (more hygienic or less traumatic)

Antifungal - miconazole gel (applied to denture fit surface) except warfarin & statin pt

Review - if lack of resolution consider systemic issue or lack of compliance

Question 23

Clinical presentation of median rhomboid glossitis?

Answer 23

Asymptomatic diamond-shaped smooth erythematous area at junction between anterior 2/3rd & posterior 1/3rd of tongue (anterior to circumvallate papillae)

Localised candida infection leading to filiform papillae atrophy

‘Kissing lesion’ = similar patch on palate

Question 24

What is associated with median rhomboid glossitis?

Answer 24

Smoking & corticosteroid use (asthmatics)

Question 25

Aetiology of angular cheilitis?

Answer 25

Multi-factorial infection with C. albicans, S. aureus & B-haemolytic streptococci

Question 26

Clinical presentation of angular cheilitis?

Answer 26

Symmetrical erythematous fissuring at commissures +/- yellow crusting

Question 27

What is the main demographic associated with angular cheilitis?

Answer 27

Elderly edentulous pts with denture stomatitis Decreased vertical dimension => maceration of underlying skin by saliva

Question 28

Risk factors of angular cheilitis?

Answer 28

Lip morphology Malnutrition - Reduced haematinic levels (iron, B12, folate) - Malabsorption disorders (e.g. Crohns, OFG) Immunosuppression (e.g. HIV) Diabetes Broad-spectrum antibiotics Xerostomia (e.g. age, medication related or Sjogren's)

Question 29

Management of angular cheilitis?

Answer 29

Correct predisposing factor (e.g. increase denture OVD) Treat candida infection - I/O = topical antifungal - E/O = miconzaole gel applied to corners of mouth

Question 30

How to treat chronic angular cheilitis?

Answer 30

Trimovate cream application (Triad: antifungal, antibacterial & steroidal)

Question 31

Why take a microbial sample?

Answer 31

Identify candida species & their antifungal resistance Identify candida quantity

Question 32

Sampling methods & advantages & disadvantages?

Answer 32

Whole saliva culture + Gives fungal load - Not suitable in xerostomia Concentrated oral rinse + Gives fungal load Swab + Site specific - Not quantitative Smear + No lengthy culture required - Candida species not identified Sponge imprint culture + Gives fungal load + Site specific Biopsy + Indicated for CHC - MOS procedure

Question 33

How to polyenes work & give example?

Answer 33

Fungicidal - generate pores in cell membrane => leakage Not absorbed by gut e.g. Nystatin

Question 34

How do azoles work & give example?

Answer 34

Fungostatic - interfere with ergosterol fungal cell membrane synthesis e.g. Miconazole, fluconazole

Question 35

When do you give topical antifungal agents?

Answer 35

Superficial infections e.g. Denture wear, antibiotic drug use or diabetics

Question 36

How is miconazole gel applied & what risks?

Answer 36

To affected area or fit surface of denture (can be left in) GIT absorption => serious interactions with warfarin & statins

Question 37

When do you use systemic antifungals?

Answer 37

Immunosuppressed Candidal leukoplakia