Fungal Infections and Orofacial tissue

Question 1

what is the primary organism in candida?

Answer 1

candida albicans

Question 2

what are the risk factors of candida?

Answer 2

smoking
denture/orthodontic appliance wear
dry mouth
carbohydrate-rich diets (feed the bugs)
immune-modulating drugs including steriods (inhalors, topical creams and oral tablet forms)
- immunocompromised pts (diabetes, HIV, chemo, radiotherapy, even short term broad spectrum antibx)
- nutritional deficiency states (ferritin, folate, B12)
- local causes including inflammatory lesions of the oral mucosa or wounds which breach the epithelium
- acidic intraoral environment (due to acid reflux in GORD or chronic vomiting)

Question 3

what are the symptoms of candida?

Answer 3

can very from asymptomatic to discomfort and burning pain or dsyastehsias (unusual sensations) and taste abnormalities

Question 4

what is candidosis?

Answer 4

ORAL function infections

Question 5

what is acute pseudomembranous candidosis?

Answer 5

also known as thrush
- creamy white plaques which may be wiped away with gauze; leaving a raw looking erythematous base
- usually asymptomatic
- can present on the palate or tongue

Question 6

who would you commonly see acute pseudomembranous candidosis presents in?

Answer 6

babies or the elderly

Question 7

when is it common to develop acute pseudomembranous candidosis?

Answer 7

after broad spectrum antibiotics or steroid inhaler use

Question 8

what is erythematous candidosis?

Answer 8

• also known as denture stomatitis
• related to poor denture hygiene/sleeping with dentures in

Question 9

what can Erythematous candidosis present as in the mouth?

Answer 9

erythema = mucosal inflammation (red patches on the dorsum of the tongue / palatal lesions - commonly in HIV pts)

Question 10

what is angular cheilitis?

Answer 10

seen at the corners of the mouth and may be very sore
- may be fungal or bacterial (due to overgrowth of staphylococcal aureus/streptococci species

Question 11

how might angular cheilitis occur?

Answer 11

• from rare skin condition (orofacial granulomatosis) - classic features of swelling in your lips, mouth and face
• or chronically in those who have lost vertical face height +/- have pronounced nasolabial folds where saliva collects = soaking (maceration) occurs and the moist warm environment is great for microbes to thrive in

Question 12

what is chronic hyperplastic candidosis?

Answer 12

potentially malignant condition

Question 13

who is at greater risk of Chronic hyperplastic candidosis?

Answer 13

smokers

Question 14

wher does Chronic hyperplastic candidosis commonly present?

Answer 14

commissural mucosa (anterior aspect of buccal mucosa often extending along the occlusal plane)
other sites: IO: dorsal of the tongue

Question 15

how might chronic hyperplastic candidosis present?

Answer 15

flat white ‘crazed’ plaques but might see hyperplasia = thickening and raised areas

Question 16

why are topical antifungals not sufficient in chronic hyperplastic candidosis?

Answer 16

the infection with Candida is deeper than previous forms - the hyphae burrow into the superficial layers of the epithelium so topical antifungals are not sufficient

Question 17

what is chronic mucocutaneous candidosis?

Question 17

what is chronic mucocutaneous candidosis?

Answer 17

group of rare, overlapping syndromes that have in common a clinical pattern of persistent, severe and diffuse mucocutaneous (pertaining to mucous membranes and skin) candidal infections of skin, nails and mucous membranes. unifying feature of these heterogeneous (diverse) disorders is impaired cell-mediated immunity against Candida but morbidity is often significant
- manifests in infancy or early childhood for most (up to 80% of cases)
- CMC may occur in conjunction with endocrine disorders (hypoparathyroidism and Addison’s disease)

Question 18

what is addisons disease?

Answer 18

adrenal insufficency with low cortisol levels

Question 19

what is the management for fungal candida?

Answer 19

1. identify all of the risk factors (modify ones that can be modified)
   –> smoking cessation
   –> improved denture hygiene
   –> rinsing after inhaled steroid use
   –> improved diabetic control
2. swabs and oral rinses (useful when infection is persistent despite risk factor modification or medication
3. Bloods?
   → Full blood count - may see anaemia
   → Haematinics - reveal deficiencies in ferritin, B12 or folate levels
   → HbA1C shows prior 90-days of blood glucose control and used to monitor and diagnose diabetes
   → HIV serology may be indicated
4. consider prescribing antifungal medication
5. plan a review of the pt
   –> if no improvement, referral is appropriate

Question 20

what are some types of antifungal medications commonly used?

Answer 20

chlorhexidine, polyenes (nystatin), azoles (fluconazole)

Question 21

what are some of the long-term effects of chlorhexidine? (3)

Answer 21

• discolouration of teeth/dentures
• taste disturbances
• dysasthesias

Question 22

what drug-drug interactions do Miconazole and fluconazole have?

Answer 22

WARFARIN AND STATINS

Question 23

when treating angular cheilitis why should you give topical and intraoral medications?

Answer 23

mouth is intraoral reservoir of the bug (need topical tx for commissures) alongside IO or recurrence will follow!

Question 24

why might a patient be unresponsive to interventions despite being compliant?

Answer 24

undiagnosed or potentially life threatening underlying systemic cause

Question 25

what are mould infections?

Answer 25

type of fungi that has no chlorophyll and cannot make its own food

Question 26

what are some examples of rare mould infections in immunocompromised patients?

Answer 26

zygmomycosis
aspergilllosis
exophalia