Topic 147: Fungal diseases of the oral mucosa.

Etiology and pathogenesis, clinical

picture, diagnostics, differential diagnostics, treatment, prevention.
5. Questions for knowledge control:
1. Etiology of the oral fungal mucosa diseases.
2. Clinical forms of candidiasis:
a) acute forms, clinical picture, differential diagnostics;
b) chronic forms, clinical picture, differential diagnostics.
3. Principles of candidiasis diagnostics.
4. Treatment of the candidiasis.
5. Prevention of the candidiasis.
CANDIDIASIS (MONILIASIS, SOOR, THRUSH)
It is an inflammatory (fungal) condition. The predilection site is the oral mucosa
from which it may spread to the mucous membrane of the pharynx, esophagus or
airways.
Etiology: The disease is caused by yeast (usually yeast of the Candida genus
such as C. albicans, C. glabrata, C. tropicalis) which is a saprophyte of the oral
cavity at normal conditions (in 40-50% of healthy individuals in our population).
Yeast can overgrow in predisposed individuals with lowered local or general
immunity. A number of predisposing factors (physiological - gravidity,
pathophysiological - trauma, chemical injury to the mucosa, severe infections,
endocrine disorders - diabetes mellitus, malabsorption, blood diseases - leukemia,
agranulocytosis, aplastic anemia, medicines from certain groups immunosuppressants, corticoids, cytostatics and broad-spectrum antibiotics that also
inhibit the growth of other microorganisms). Some properties of yeast play an
important role in the pathogenesis, for example yeasts ability to adhere to the
surface of the oral mucosa (as well as to the surface of plastics) or grow in the
epithelial covering of the oral mucosa. This results in transformation from the
saprophytic into the parasitic mode of existence. Many local and general factors are
involved in this process. Their number is increasing, which increases the number of
predisposed individuals (and those who are at risk).
Clinical picture is very varied. There are many clinical forms that may not
always have the characteristic appearance of a disease belonging to a group of
diseases of the oral mucosa called the white patch syndrome.
Acute pseudomembranous candidiasis is the most common, typical form of
oral candidiasis. It develops abruptly, being manifested by the formation of whitish,
partially removable coatings - pseudomembranes (resembling precipitated milk) that
are produced by yeast colonies. They do not have a typical predilection site in the
oral cavity. Their occurrence on the gingiva is not typical. The growth of
pseudohyphae into the superficial layers of the mucosal epithelium results in the
strong adhesion of coatings to the mucosa. After they are peeled off, the mucosa will
bleed and erosions will develop on the mucosa. The mucosa of the oral cavity in the
surroundings of coatings has a distinct red discolouration. Subjective difficulties are
varied including a burning sensation, increased sensitivity or pain of the affected

mucosa, impaired taste sensation. Painful swallowing indicates the progression of

fungal infection into the swallowing routes. If the inflammation does not heal
spontaneously (or after therapy), it may progress to the chronic stage or to the
dissemination or generalization of the process.
Acute erythematous candidiasis usually develops due to dysmicrobia in the
oral cavity or GIT, as a result of therapy using broad-spectrum antibiotics.
Clinically, it presents as diffuse reddening of the mucosa (without
pseudomembranes) associated with burning sensation, pain and dryness in the oral
cavity. Mycotic angular stomatitis (anguli infectiosi) can be present. It disappears
quickly at adequate therapy (with the simultaneous modification of microflora in the
digestive tract).
Chronic pseudomembranous candidiasis is another form of yeast-induced
inflammation. It is a severe disease of the oral mucosa with a risk of the
dissemination and generalization of the process. It particularly affects
immunodeficient and cancer patients. It is usually vast and spreads into the
oropharynx and other parts of the swallowing and respiratory routes. Subjectively,
there are only difficulties swallowing. It does not usually heal spontaneously; the
success of therapy depends on the patient's general condition and the efficacy of
antifungal therapy.
Chronic hyperplastic candidiasis is a less common form of oral candidiasis. It
is always a long-time disease (months - years) and can occur within chronic
mucocutaneous candidiasis, particularly in individuals with congenital
immunological abnormalities. It occurs in childhood and is usually associated with
some polyendocrinopathies, for example with the simultaneous hypofunction of the
adrenal cortex and parathyroid gland, or myasthenia. Subjective problems are
minimal, or can be absent in some cases, which is in contrast to the major extent of
the disease (white patches that cannot be removed, usually occurring on the buccal
mucosa and tongue with calm surroundings, without reddening). Therapy is difficult
since the disease is refractory to treatment.
Chronic erythematous, atrofic candidiasis - It usually occurs as prosthetic
stomatitis in individuals with removable dental prosthesis. The mucosa of the
prosthetic bed is usually diseased, showing massive hypertrophy or papillomatous
hypertrophic mucosa. This form tends to recur - probably, it is constant reinfection
where the prosthesis serves as a reservoir of yeast. The optimum solution is to make
a new dental prosthesis and prevent the development of oral candidiasis through the
proper care of the prosthesis. The mucosa on the dorsum of the tongue is another
common site of chronic atrophic candidiasis. It has a distinct red discolouration,
without a coating, sometimes showing papillomatous hypertrophy with calm
surroundings.
Angular candidiasis affects the mucosa of mouth corners alone or in
combination with a more extensive affliction of the oral cavity. Its typical
symptoms include crevices and red patches with an indistinct, white margin of the
labial mucosa, usually bilaterally. Deep defects such as fissures are not usually
formed, being accompanied with bleeding or purulent exsudate and crusts.
Bacteriological tests usually reveal Staphylococcus aureus. Patients also show the
decreased height of occlusion in the defective dentition with unsatisfactory dental

prostheses. The maceration of mouth corners with saliva causes symptoms to

aggravate further. In children, secondary streptococcal infection (impetigus) may
occur and spread into the surrounding facial skin.
In countries with a higher incidence rate of HIV-positive individuals and
patients with AIDS symptoms in the oral cavity, the clinical spectrum of oral
candidiasis becomes broader. Oral candidiasis is a typical symptom of AIDS in the
oral cavity, characterized by the formation of whitish margins and
pseudomembranes on the gingiva. Symptoms of yeast infection are combined with
other infectious and non-infectious pathological manifestations. Causative agents
can include Cryptococcus neoformans, Histoplasma capsulatum, Blastomyces
dermatidis, Rhyzopus oryzae and R. arrhizus. Manifestations of oral candidiasis also
include other, less common diseases of the lingual mucosa that are - together with
prosthetic stomatitis - referred to as Candida-associated lesions
6. The practical skills on the topic:
1) to be able to work on the dental equipment;
2) to be able to work with dental instruments, to know of the rules of sterilization;
3) to be able to make recording and reporting documentation for therapeutic
dentist and to make analysis of performance;
4) to be able to conduct the clinical examination of the patient with oral mucosa
pathology in the mouth, to make correctly of the medical history, to make plan
of examination and treatment of patient;
5) to be able to perform and assess condition of hygiene in the mouth;
6) to be able to take the material for bacteriological tests, to analyze the results;
7) to be able to analyze the results bacteriological tests of the bacteriological tests
of patient, clinical analysis of blood, urine, biochemical analysis of blood on the
glucose;
8) to be able to perform application and non-infiltration nerve block anesthesia;
9) to be able to perform application, irrigation and instillation medical drugs;
10) to be able to write down the recipe, to appoint physiotherapy treatment;
11) to be able to perform professional hygiene of oral cavity;
12) to be able to make recommendations about choice of means and objects of
the hygiene of oral cavity, prevention of complications.
7. Terminology: candidiasis, Candida albicans.
8. Questions for knowledge control:
6. Etiology of the oral fungal mucosa diseases.
7. Clinical forms of candidiasis:
c) acute forms, clinical picture, differential diagnostics;
d) chronic forms, clinical picture, differential diagnostics.
8. Principles of candidiasis diagnostics.
9. Treatment of the candidiasis.
10.Prevention of the candidiasis.
Tests:
1. A 3-month-old child has been in disease state for two days. The child is anxious,

refuses food, has normal body temperature. Objectively: mucous membrane of oral
cavity is edematic and hyperemic. There is white caseous coating on the back of tongue
and buccal mucosa. After the coating removal one can see extremely hyperemic surface
with petechial haemorrhages. What is the most likely diagnosis?
A. Acute candidal stomatitis
B. Mild leukoplakia
C. Herpetic angina
D. Lichen ruber planus
E. Acute herpetic stomatitis
2. Analysis of the contents of periodontal pockets revealed a significant contamination
with Candida yeast fungi. Which of the following drugs should be used for instillations?
A. Trichopol
B. Diclofenac sodium
C. Clotrimazole
D. Dioxydin
E. Tinidazole
3. 12-year-old patient complains of the pain and that the tongue feels burned. Case
history: biliary duct dysfunction. The patient is staying in the hospital and treating with
systemic steroids for reason of asthma. Intraoral examination: oral mucosa is swollen,
there are a tooth prints on the occlusal plane of the mucous membrane. Some separated
areas of white plaques are seen on the dorsal surface of the red, enlarged tongue. The
patient also complains of an unpleasant taste. The tentative diagnosis is acute oral
candidasis (glossitis). What findings of clinical examination indicate the oral candidasis?
A. Systemic steroid treatment.
B. Asthma.
C. Red tongue with white plaques.
D. Tooth prints on the lateral tongue.
E. Unpleasant taste.
4. 11-year-old girl complains about burning sensation in the tongue. Case history: she
used antibiotics prescribed by gynecologist during one week. Intraoral examination: oral
mucosa is swollen, there are a tooth prints on the occlusal plane of the mucous
membrane. Some separated areas of white plaques are seen on the dorsal surface of the
red, enlarged tongue. The patient also complains of an unpleasant taste. The tentative
diagnosis is acute oral candidasis (glossitis). What is the main important syndrome in this
case?
A. Swelling of the oral mucosa.
B. Red colour of the tongue.
C. White plaques on the dorsal tongue.
D. Tooth prints on the lateral tongue.
E. Unpleasant taste.
5. 17-year-old girl is sick and staying in the hospital caused by acute bronchitis. Some
antibiotics are used for her treatment. After fifth day of therapy the pseudomembranous

plaques has arisen on the inflamed oral mucosa. These plaques resembling curdled milk
can be difficult scraped off, leaving the painful erosive areas behind. What is the tentative
diagnosis likely to be?
A. Allergic reaction caused by medications.
B. Acute Atrophic Candidasis.
C. Acute Oral Candidasis.
D. Primary Herpes Simplex infection.
E. Oral lesions caused by Diphtheria
5

11.In 30-year-old patient was found to have acute oral candidasis, middle degree of
progression. What topical drugs group should you use first of all?
A. Antibiotics.
B. Hypoallergenic medication.
C. Antifungal drugs.
D. Anesthetics.
E. Topical drugs are favorable for epithelization
12.The parents of 1,5 month-old baby complain of presence whitish deposits on the oral
mucosa of the cheeks and lips. Exam: oral mucosa of the affected sites is swollen,
erythematous and covered with curdled-like plaque, which can be easily scraped off.
What is the causative agent of that disease?
A. Fusospirillar symbiosis
B. Candida albicans
C. Herpes simplex virus
D. Loeffler's bacillus
E. Neissers diplococcic
13.Candidasis is a complication of all the following except:
A. Antibiotic therapy
B. Steroid therapy
C. Immune compromised diseases
D. Aspiration pneumonia
E. Bacterial misbalances