Fungal infections in the mouth are due to the candida species.

Many types of candida species already exist in the mouth especially candida albicans, however they are opportunistic pathogens that increase in number orally when the conditions are right (e.g. immunocompromised patients). This leads to a fungal infection.

When it comes to candidal infections there are typical tests that are done in order to diagnose the type of candidal infection it is. These tests are:

  • Swab test – A sterile cotton swab is rubbed on the lesion. The swab is sent to microbiology where the culture specimen is grown and then analysed. This can take a few days but it is a more accurate test compared to smear test.
  • Smear test – Cells from the lesion are wiped using a brush. The smear is sent to histology where the specimen is stained and viewed under a microscope. This is much quicker than the swab test but not as accurate.

There are many different types of oral candidal infections. These are categorised in a number of different ways due to the different oral manifestations they present with. A few ways they can be categorised are the following:

  1. Onset and duration e.g. Chronic? Acute?
  2. Clinical features e.g. Atrophic? Erythematous?
  3. Location e.g. Median? Angular?
  4. Presence of skin lesions e.g. Mucocutanous?
  5. Association with immunocompromised e.g. HIV associated?

The causes of candidal infections are outlined below:

Corticosteriod Inhalers

  • Immunosuppression causes a decrease in the number of functional B and T lymphocytes.

Tissue Trauma

  • Minor trauma to oral mucosa can provide a channel for candida to invade oral tissues.

Dry Mouth

  • A decrease in saliva reduces the exposure of candida to antimicrobial agents (IgA).

Physiological Immunodeficiency

  • HIV/AIDS
  • Infancy/ old age
  • Diabetes
  • Anaemia
  • Chemotherapy

Antibiotics

Broad spectrum antibiotics create a ‘clean slate’ that allows candida to colonise mucosa uncontested.

Acute Pseudomembranous Candidosis (Thrush)Acute Atrophic CandidosisChronic Erythematous CandidosisMucocutanous Candidosis Chronic Hyperplastic CandidosisAngular CheilitisMedian Rhomboid GlossitisReferences

Overview

  • Most common form of candidosis
  • Commonly known as thrush
  • Seen in all age groups
  • More common in women

Clinical Signs

  • Prodromal symptoms include: rapid onset of bad taste, loss of taste discrimination, burning sensation of mouth and throat
  • Thick white coating that resembles cottage cheese
  • When wiped it reveals an area of erythema and often bleeding if severe
  • Lesions can occur on any mucosal surface and the size can vary
  • Angular stomatitis is frequently associated, as it is with most intra oral candidosis diseases

Histological Features

  • Hyperplastic epithelium
  • Infiltration of superficial layers by yeast and inflammatory cells (such as neutrophils, lymphocytes etc)

Risk Factors

  • Inhalational corticosteroids
  • Broad spectrum antibiotics
  • Immunosuppressive therapy
  • Xerostomia/sjogren syndrome
  • Diabetes
  • HIV
  • Nutritional deficiencies
  • Local irritants such dentures and orthodontic appliances

Diagnosis

  • Diagnosed through symptoms and signs
  • Swab test
  • Smear test

Treatment

Local measures:

  • Advise patients who use a corticosteroid inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler.

If drug treatment is required, an appropriate 7-day regimen is a choice of:

  • Fluconazole capsule
  • Miconazole oromucosal gel

Azole-antigfungals (those above) are contraindicated when the patient is taking warfarin or statins. In such a patient prescribe:

  • Nystatin Oral Suspension

See SDCEP

Commonly knows as antibiotic sore mouth.

Clinical Signs

  • Red painful area of the oral mucosa (usually dorsum of tongue)
  • Depapillation of tongue
  • Doesn’t have the white pseudo-membranous lesions observed in thrush
  • Associated with burning mouth syndrome, bad taste and sore throat

Risk Factors

  • Inhalational corticosteroids
  • Broad spectrum antibiotics
  • Immunosuppressive therapy
  • Xerostomia
  • Diabetes
  • HIV
  • Nutritional deficiencies

Diagnosis

  • Swab test
  • Smear test

Treatment

Local measures:

  • Advise patients who use a corticosteroid inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler.

If drug treatment is required, an appropriate 7-day regimen is a choice of:

  • Fluconazole capsule
  • Miconazole oromucosal gel

Azole-antigfungals (those above) are contraindicated when the patient is taking warfarin or statins. In such a patient prescribe:

  • Nystatin Oral Suspension

See SDCP

Commonly known as Denture Stomatitis

Clinical Signs

  • Chronic erythema
  • Oedema
  • The affected mucosa will mark the denture bearing areas
  • Palate is usually affected and its rarely seen in lowers as as there is better salivary flow
  • 3 patterns of inflammation exist:
    • Pin-point
    • Erythema limited to the denture bearing area
    • Erythema associated with a hyperplastic nodular reaction

Risk Factors

  • Inhalational corticosteroids
  • Broad spectrum antibiotics
  • Immunosuppressive therapy
  • Xerostomia
  • Diabetes
  • HIV
  • Nutritional deficiencies
  • Poorly fitting denture
  • Poor denture hygiene

Diagnosis

  • Normally through clinical signs
  • Swab test
  • Smear test

Treatment

  • Manage any predisposing factors e.g denture care

Local measures

  • Advise patients who use a corticosteroid inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler.

If drug treatment is required, an appropriate 7-day regimen is a choice of:

  • Fluconazole capsule
  • Miconazole oromucosal gel

Azole-antigfungals (those above) are contraindicated when the patient is taking warfarin or statins. In such a patient prescribe:

  • Nystatin oral suspension

See SDCP

Overview

This a rare condition caused by an immune disorder of T cells. Clinical manifestation can be of many forms so it can be difficult to diagnose through observation alone.

Normally in an infection (e.g. candida infection) TH-17 cells (T-HELPER) are made by the immune system which in turn produce IL-17, inflammation is induced and white blood cells confront the infection. In mucocutaneous candidiasis mutations affect IL-17 by inhibiting the pathway, so infections cannot be fought as they normally would be.  

Infection develops during early childhood and persist leading to infection of the oral mucosa, scalp skin and nails. The mouth, eyelids and digestive tract can also be affected. 

Clinical Features

Wide variety of clinical manifestation exist but the following are quite indicative of mucocutanous candidosis:

  • White plaques, with crusts and ulcers 
  • Can affect skin, mucous membrane and nails 
  • Many people will also have underlying conditions specifically endocrine disorders, hepatitis, meningitis and autoimmune diseases 
Oral manifestation
via @all_things_oral_medicine

Diagnosis

  • Genetic testing to check for genetic mutation  
  • Biopsy 
  • Smear test
  • Swab test
  • If the patient doesn’t have a risk of candida infection, then an underlying condition may be expected 

Treatment

  • Topical antifungals such as miconazole
  • Systemic antifungals such as fluconazole

Potentially malignant (high risk)

This is also known as candidal leukoplakia as often they start of as leukoplakia lesions then become colonised by candia albicans. (see white patches)

Clinical Signs

  • White patches found normally on the commissures of the mouth or dorsum of tongue that
  • Can’t be wiped away (like all leukoplakia lesions) 
  • Patches are off varying thickness 
  • Rough or nodular like surface 
  • Associated with angular cheilitis 

Histology

  • Epithelium is parakeratinised, hyperplastic and acanthotic (thickening of skin) 
  • Candida albicans hyphae penetrate the para-keratinised region 
  • Within the para-keratinised region cells are separated by oedema and neutrophils 
  • Chronic inflammatory infiltrate present in the lamina propria 
  • Atrophic epithelium may be present and the superficial layer of candida infected parakeratin missing 

Risk Factors

  • Tobacco smoke 
  • Denture wearing 
  • Men over 30 years 
  • Occlusal friction 

Diagnosis

Biopsy (to distinguish it from other non-candida lesions and examine for dysplasia) 

Treatment

  • Systemic anti-fungal drug such as fluconazole  
  • Alleviate any predisposing factors such as tobacco smoking 
  • Note: Chronic hyperplastic candidosis is considered a potentially malignant lesion so early detection and treatment is vital.

Clinical Signs

  • Inflammation of the corners of the mouth
  • Cracking of the mucosa at the corners of the mouth
  • Golden crusting (if caused by bacteria)
  • Multifactorial condition with local and systemic predisposing factors
  • Can be bacterial (staphylococcus aureus), fungal (candida) or mixed
  • Most common cause is candidal infection but where there is a crusting/yellow, secondary infection with staphylococcus aureus may be the cause (bacterial infection)
Angular cheilitis and Xerostomia Via @all_things_oral_medicine

Risk Factors

Localised Factors:

  • Angles of the mouth become traumatised due to constant wetting by saliva
  • Poor moisturising care
  • Reduction in OVD
  • Poorly fitting dentures
  • Vitamin B12 deficiency
  • Iron deficiency
  • Zinc deficiency

Systemic Factors:

  • Angioedema
  • Crohn’s disease
  • Orofacial granulomatosis

Diagnosis

  • Through clinical signs
  • Identify habits which affect corners of the mouth
  • Full blood count– haematological deficiency

Treatment

Initially prescribe one of the following:

  • Miconazole cream – for bacterial and fungal cause
  • Sodium fusidate ointment – for bacterial cause only

If unresponsive prescribe one of the following:

  • Miconazole and Hydrocortisone cream
  • Miconazole and Hydrocortisone ointment

See SDCEP

Clinical Signs

  • Depapilation of the dorsal surface of the tongue in the midline
  • Affected area is smooth, shiny and symmetrical
  • Around the midline and anterior to circumvallate papillae
  • Asymptomatic
  • Lesion can spread to palate as tongue is normally in contact with palate – this is known as kissing lesion
Median rhomboid glossitis treated with antifungals
Via @all_things_oral_medicine

Risk Factors

  • Inhalational corticosteroids
  • Broad spectrum antibiotics
  • Immunosuppressive therapy
  • Xerostomia
  • Diabetes
  • HIV
  • Nutritional deficiencies

Diagnosis

  • Swab test
  • Smear test

Treatment

Local measures:

  • Advise patients who use a corticosteroid inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler.

If drug treatment is required, an appropriate 7-day regimen is a choice of:

  • Fluconazole capsule
  • Miconazole oromucosal gel

Azole-antigfungals (those above) are contraindicated when the patient is taking warfarin or statins. In such a patient prescribe:

  • Nystatin oral suspension

See SDCEP

Akpan. A, Morgan.R. (2002). ‘Oral Candidiasis’. Postgraduate Medical Journal. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742467/pdf/v078p00455.pdf

Cawson. R A, Odell. E W. (2008). Cawson’s Essentials of Oral Pathology and Oral Medicine. 8th Edition. Pages 213-219.

Dental Update: Oral Medicine – White patches: https://www.dental-update.co.uk/issuesSingleIssueArticle.asp?aKey=833

See also Facial Pain