Candidiasis Oral – Kompetensi 4A

A. Definisi
Kandidiasis oral adalah penyakit pada rongga mulut yang disebabkan oleh pertumbuhan
abnormal dari jamur Candida albicans.

B. Risk Factor
Status kekebalan host, lingkungan mukosa oral, strain Candida albikans.
C. Fungus
Fase pengembangan biofilm dalam C. albicans. Siklus hidup biofilm C. albicans terdiri
dari perlekatan sel C. albicans bebas ke permukaan, pembentukan hifa, produksi matriks
ekstraseluler, dan detasemen (dispersi) sel yang dapat memulai pembentukan biofilm di
lokasi baru. Untuk kesederhanaan, beberapa gen termasuk faktor transkripsi (dalam huruf
tebal) yang terlibat dalam tahap yang ditunjukkan (sebagaimana diidentifikasi dalam kondisi
in vitro dan in vivo) disajikan dalam kotak. Tanda panah menunjukkan sifat sel ragi yang
terdispersi seperti peningkatan kepatuhan, virulensi, dan resistensi antijamur.
Candida albicans host innate system evasion strategies. (A) Yeast- to hyphal-phase
transition. (B) Downregulation of epithelial TLR4 expression. (C) Shielding of PAMP from
PRR recognition. (D) Inhibition or degradation of complement system. (E) Inhibition of
phagolysosome formation. (F) Modulation of T cell function.

Schematic diagram of the interplay between Candida albicans and host innate immune

systems at the mucosal surface. Black lines denote host defense mechanisms. Red lines
denote Candida invasion/escape mechanisms.
D. Klasifikasi
Menurut klasifikasi oral candidosis yang sudah direvisi
Primer (Group I) Sekunder (Group II)
Akut Manifestasi oral dari mukokutaneus
- Pseudomembranous sistemik
- Eritematous
Kronik
- Eritematous
- Pseudomembranous
- Hiperplastik
- Nodular
- Plaque-like
Candida associated lesion Kandidosis (berhubungan dengan penyakit
- Denture stomatitis seperti aplasia timus dan candidosis sindrom
- Angular cheilitis endokrinopati)
- Median rhomboid glossitis
Keratinized primary lesion superinfected
with candida
- Leukoplakia
- Lichen planus
- Lupus erythematosus
 Trias Primer
1. Pseudomembraneus candidiasis  pada permukaan oral, terdapat plak
berkonfluens kreamy putih hingga putih kekuningan seperti milk curds atau cottage
cheese. Plak terdiri dari desquamated epithelial cells, tangled aggregates of fungal
hyphae, fibrin, dan necrotic material. The superficial pseudo-membrane can be
removed by wiping gently, leaving behind an underlying erythematous and
occasionally bleeding surface. The symptoms of the acute form are rather mild and
the patients may complain only of slight tingling sensation or foul taste, whereas, the
chronic forms may involve the oesophageal mucosa leading to dysphagia and chest
pains. Few lesions mimicking pseudomembranous candidiasis could be white coated
tongue, thermal and chemical burns, lichenoid reactions, leukoplakia, secondary
syphilis and diphtheria
2. Erythematous candidiasis. Previously known as ‘antibiotic sore mouth,’ due to its
association with prolonged use of broad-spectrum antibiotics. The chronic form is
usually seen in HIV patients involving the dorsumof the tongue and the palate and
occasionally the buccal mucosa. it manifests as painful localized erythematous area. It
is the only form of candidiasis associated with pain. The lesions are seen on the
dorsum of the tongue typically presenting as depapillated areas. Palatal lesions are
more common in HIV patients. Differential diagnosis may include mucositis, denture
stomatitis, erythema migrans, thermal burns, erythroplakia, and anemia.

3. The hyperplastic candidiasis mainly presents as chronic form. It has been commonly
referred previously by several authors as ‘candidal leukoplakia.’ Clinically, it may
manifest as one of the two variants; homogeneous adherent white plaque-like or
erythematous multiple nodular/speckled type. The lesions usually occur bilaterally in
the commissural region of the buccal mucosa and less frequently on the lateral border
of the tongue and palate. Unlike the pseudomembranous type, hyperplastic candidiasis
lesions are non-scrapable. Bisa dysplasia. Confirmed association between Candida
and oral cancer is yet to be recognized, although in vitro studies have shown that the
candida organisms can generate carcinogenic nitrosamine. Differential diagnosis may
include leukoplakia, lichen planus, angular cheilitis and squamous cell carcinoma.

Candida-associated Lesions
1. Denture stomatitis. It is also known as “chronic atrophic candidiasis.” As the
name indicates, it is chronic inflammation of the mucosa typically restricted to the
denture-bearing area, seen in association with candidiasis. Clinically, the lesions
may be seen as pinpoint hyperaemia, diffuse erythematous or granular/papillary
type. It occurs frequently along with angular cheilitis and median rhomboid
glossitis. The lesions are usually asymptomatic, though occasionally patients may
complain of burning sensation or soreness. It commonly affects the palate
although mandibular mucosa may also be affected.

2. Angular cheilitis. This form of candidiasis usually manifests as erythematous or

ulcerated fissures, typically affecting unilaterally or bilaterally the commissures of
the lip. Angular cheilitis often represents an opportunistic infection of fungi and/or
bacteria, with multiple local and systemic predisposing factors involved in the
initiation and persistence of the lesion. The factors associated include old age and
denture-wearers (due to reduced vertical dimension), vitamin B12 deficiency and
iron deficiency anemia.
3. Median rhomboid glossitis. Median rhomboid glossitis appears as the central
papillary atrophy of the tongue and is typically located around the midline of the
dorsum of the tongue. It occurs as a well-demarcated, symmetric, depapillated
area arising anterior to the circumvallate papillae. The surface of the lesion can be
smooth or lobulated. While most of the cases are asymptomatic, some patients
complain of persistent pain, irritation, or pruritus. It is commonly seen in tobacco
smokers and inhalation-steroid users.

4. Linear gingival erythema. It was previously referred to as “HIV-gingivitis” since

its typical occurrence was in HIV associated periodontal diseases. It manifests as
linear erythematous band of 2– 3 mm on the marginal gingiva along with
petechial or diffuse erythematous lesions on the attached gingiva. The lesions may
present with bleeding.
 Oral Candida infection in newborn
The most common form of candidiasis affecting this age group is the acute
pseudomembranous candidiasis. Treatment for superficial infection is topical administration
of antifungals such as 1% clotrimazole solution thrice daily for 7 days. In case of invasive or
disseminated candidiasis, systemic interventions are obligatory.

E. Diagnosis
F. Managemen
Guideline managemen efektif:
1. Diagnosis dengan riwayat penyakit dan dental history, manifestasi klinis, dan
dikonfirmasi menggunakan uji laboratoris.
a. Tanda dan gejala
b. Adanya spesies Candida dalam direct examination smear atau biopsy (ada hifa di
epitel, kultur, test serologi)
2. Koreksi factor predisposisi
3. Pertahankan hygiene kavitas oralis dan prostesa oral
4. Pemilihan antifungal sesuai keparahan infeksi dan ketepatan terhadap prevalensi spesies
Candida pada pasien. Pemilihan antifungal didasarkan pada nature lesi dan status
munologi pasien. Ada 3 kategori: the cell membrane, cell wall, and nucleic acids
a. Polyenes: nystatin, amphotericin B
b. Inhibitor biosintesis ergosteror: azol (miconazole, clotrimazole, ketoconazole,
itraconazole, and fluconazole), allylaminesthiocarbamates, and morpholines
c. and DNA analog 5-fluorocytosine, and newer agents such as caspofungin
 Superficial oral candidosis pada orang sehat dapat diobati dengan obat topical,
pada orang imunokompremais harus dengan obat sistemik dan topical. Pada pasien
dengan factor risiko yang persisten dan kasus relapse harus diberi antifungal dengan
risiko resisten terkecil.
Antifungal dengan level tinggi di epitel oral dapat dicapai dengan antifungal
topical. Polyenes adalah obat fungisidal yang menempellangsung ke ergosterol pada
membrane sel menimbulkan kebocoran isi sitoplasma dan menyebabkan kematian sel
fungi. Larutan Nystatin atau amphotericin B dipakai selama 4 minggu dan pada kasus
berulang durasinya menjadi minimal 4-6 minggu.
Gel miconazole yang dapat digunakan unruk infeksi tanpa komplikasi dan
digunakan hingga 1 minggu setelah gejala menghilang. Gel ini menghambat sintesis
ergosterol, berinteraksi dengan sitokrom P450 enzim 14-alfa demethylase, menghambat
pertumbuhan yeast patogenik dengan mengubah permeabilitas membrane sel.
Penggunaan miconazole berulang dapat mengakibatkan terbentuknya strain resiten azole.
Antifungan sistemik
Diindikasikan pada kasus imunokompromais atau kasus diseminata. Azole adalah
fungistatic yang menghambat enzim lanosterol demethylase fungi untuk sistesis
ergosterol. Fluconazole memiliki konsentrasi tertinggi di saliva. Fluconazole dan
itraxonazole digunakan secara oral dan akan disekresikan ke membrane mukosa.
Antifungal lain seperti echinocandin menghambat D-glucan synthase dan flucytosine
menghambat sintesis DNA/protein.
Posaconazole hanya terdapat dalam sediaan ral solution dan digunakan pada pasien
imunokompromais dan yang resisten obat lainnya. Penggunaan azole memiliki risiko
strain resistensi. Rekomendasi ntuk penyakit refraktori fluconazole:
a. Fluconazole-refractory diseaseitraconazole solution 200 mg/hari atau
posaconazole suspension 400 mg 2x1 selama 3 hari, dilanjutkan 400 mg/ hari
hingga 28 hari
 b. Jika agen lain gagal  Voriconazole 200 mg 2x1 atau 1-mL oral suspension
AmB-d 100 mg/mL 4x1
c. Refractory disease IV echinocandin atau AmB-d 0.3 mg/kg/hari

Obat Herbal alternative

1. Essential oil Melaleuca alternifolia (tea tree oil)
2. Xylitol sebagai gum atau oral rinse mampu menghambat metabolisme mikroba di
kavitas oralis sehingga dapat mencegah tercampurnya infeksi dari biofilm
 3. Berberine-containing plants; caprylic acid; grapefruit seed extract; garlic; probiotics;
tea tree oil and enteric-coated volatile oil preparations containing cinnamon, ginger,
oregano, peppermint and rosemary; propolis and thyme
Prevention
1. Oral hygiene  Mechanical cleaning dengan sikat gigi
2. Oral decontamination  antifungal dan antibacterial oral rinse (bagus untuk
mucositis)
3. Chlorhexidine digluconate dan cetylpyridinium chloride adalah antiseptip oral rinse
sebagai profilaksis kemoterapi dan radioterapi yang menginduksi mucositis
4. Untuk pengguna kortikosteroid inhalasi  cuci mulut dengan air atau mouthwash
setelah memakai inhaler
5. Untuk pengguna denture  lepas saat malam dan rendam di larutan chlorhexidine
0,2% atau 15-30 menit di white vinegar (dilusi 1:20) atau 0,1% larutan hipoklorida.