By: Dr. Ameya Tripathi, Asstt. Editor-ICN
LUCKNOW: Sudden appearance of cotton like white deposits on your tongue and oral mucosa can be more than just plaque accumulation. Initially it appears harmless but can cause loss of taste and sometimes burning sensation .It can be oral thrush or candidiasis.
Oral thrush causes creamy white lesions, usually on your tongue or inner cheeks. Sometimes oral thrush may spread to the roof of your mouth, your gums or tonsils, or the back of your throat. oral candidiasis is a mycosis (yeast/fungal infection) of Candida species on the mucous membranes of the mouth.
Candida albicans is the most commonly implicated organism in this condition. Although oral thrush can affect anyone, it’s more likely to occur in babies and older adults because they have reduced immunity; in other people with suppressed immune systems or certain health conditions; or people who take certain medications. Oral thrush is a minor problem if you’re healthy, but if you have a weakened immune system, symptoms may be more severe and difficult to control.
Three main clinical appearances of candidiasis are generally recognized: pseudomembranous, erythematous (atrophic) and hyperplastic. Most often, affected individuals display one clear type or another, but sometimes there can be more than one clinical variant in the same person
CLASSIFICATIONS. Apart from various classifications available like acute, chronic based on intensity and time duration of discomfort. Then based upon their association with other disease like median glossitis, angular cheilitis, denture stomatitis. Mainly they are grouped by the type of there appearances which we are describing below.
It is characterized by a coating or individual patches of pseudomembranous white slough that can be easily wiped away to reveal erythematous (reddened), and sometimes minimally bleeding, mucosa beneath. These areas of pseudo membrane are sometimes described as “curdled milk”, or “cottage cheese”. This is most common type of oral candidiasis .
Erythematous (atrophic) candidiasis is when the condition appears as a red, raw-looking lesion. Some sources consider denture-related stomatitis, angular stomatitis, median rhomboid glossitis, and antibiotic-induced stomatitis as subtypes of erythematous candidiasis, since these lesions are commonly erythematous/atrophic. This is usually termed “antibiotic sore mouth”, “antibiotic sore tongue”, or “antibiotic-induced stomatitis” because it is commonly painful as well as red .Chronic erythematous candidiasis is more usually associated with denture wearing.
This variant is also sometimes termed “plaque-like candidiasis” or “nodular candidiasis”. The most common appearance of hyperplastic candidiasis is a persistent white plaque that does not rub off. The lesion may be rough or nodular in texture. Hyperplastic candidiasis is uncommon, accounting for about 5% of oral candidiasis cases, and is usually chronic and found in adults. The most common site of involvement is the commissural region of the buccal mucosa, usually on both sides of the mouth. Another term for hyperplastic candidiasis is “candidal leukoplakia”. This term is a largely historical synonym for this subtype of candidiasis, rather than a true leukoplakia.
Normally there are no sign and symptoms other than the appearance of the lesions. But sometimes there may be loss of taste, burning sensations, another potential symptom is a metallic, acidic, salty or bitter taste in the mouth. Sometimes the patient describes the raised pseudomembranous as “blisters.” Occasionally there can be dysphagia (difficulty swallowing), which indicates that the candidiasis involves the oropharynx or the esophagus, as well as the mouth. The trachea and the larynx may also be involved where there is oral candidiasis, and this may cause hoarseness of the voice. Sometimes the cottage cheese like typical appearance is there which your medical adviser will instantly link with oral thrush or candidiasis.
Dentures– dentures like your normal teeth, needs to be cleaned. But poor denture hygiene can predispose the growth of fungus candida albicans which can cause oral thrush. Also many denture wearers have habit of not taking out their dentures in night but wearing it. Dentures provide a relative acidic, moist and anaerobic environment because the mucosa covered by the denture is sheltered from oxygen and saliva. Loose, poorly fitting dentures may also cause minor trauma to the mucosa, which is thought to increase the permeability of the mucosa and increase the ability of C. albicans to invade the tissues.These conditions all favor the growth of C. albicans. Sometimes dentures become very worn, or they have been constructed to allow insufficient lower facial height (occlusal vertical dimension), leading to over-closure of the mouth (an appearance sometimes described as “collapse of the jaws”). This causes deepening of the skin folds at the corners of the mouth (nasolabial crease), in effect creating intertriginous areas where another form of candidiasis, angular cheilitis, can develop. Candida species are capable of adhering to the surface of dentures, most of which are made from polymethylacrylate. They exploit micro-fissures and cracks in the surface of dentures to aid their retention. Dentures may therefore become covered in a biofilm, and act as reservoirs of infection, continually re-infecting the mucosa. For this reason, disinfecting the denture is a vital part of treatment of oral candidiasis in persons who wear dentures, as well as correcting other factors like inadequate lower facial height and fit of the dentures.
Corticosteroid inhalers– as they have corticosteroid in them, they lower the immunity of the host, where opportunistic candida albicans can strike. Inhaled corticosteroids (e.g., for treatment of asthma or chronic obstructive pulmonary disease), are not intended to be administered topically in the mouth, but inevitably there is contact with the oral and oropharyngeal mucosa as it is inhaled.
Reduced salivary flow or xerostomia-drying of the mouth due to reduced salivary flow which can be result of radiation therapy or salivary gland disorder, provides an ideal environment for the fungus to grow. saliva forms the first line of defense against microbes. reduction in saliva reduces the action against them.
High sugar diet or Nutritional deficiencies. .- Malnutrition(whether by malabsorption,) or poor diet, especially hematinic deficiencies (iron, vitamin B12, folic acid) can predispose to oral candidiasis, by causing diminished host defense and epithelial integrity. For example, iron deficiency anemia is thought to cause depressed cell-mediated immunity. Some sources state that deficiencies of vitamin A or pyridoxine are also linked. There is limited evidence that a diet high in carbohydrates predisposes to oral candidiasis. In vitro and studies show that Candidal growth, adhesion and biofilm formation is enhanced by the presence of carbohydrates such as glucose, galactose and sucrose.
Extremes of age-babies and geriatric patients are most susceptible for candidiasis as immunities are down, proper cleaning and maintain of oral hygiene depends upon monitoring and supervision of others.
Endocrine disorders (e.g., diabetes)-hormonals changes and diseases like diabetes cause reduction of immunity, positive environment for the fungus resulting in candidiasis
Immunosuppression-Corticosteroid medications may contribute to the appearance of oral candidiasis, as they cause suppression of immune function either systemically or on a local/mucosal level, depending on the route of administration. Topically administered corticosteroids in the mouth may take the form of mouthwashes, dissolving lozenges or mucosal gels; sometimes being used to treat various forms of stomatitis. Systemic corticosteroids may also result in candidiasis.
Broad spectrum antibiotics (e.g., tetracycline)- they disrupt the competing bacteria and disrupt the normally balanced ecology og microbes giving an opportunity to the fungus to cause oral thrush.
The diagnosis can typically be made from the clinical appearance alone, but not always. As candidiasis can be variable in appearance, and present with white, red or combined white and red lesions, the differential diagnosis can be extensive. Special investigations to detect the presence of candida species include oral swabs, oral rinse or oral smears. Smears are collected by gentle scraping of the lesion with a spatula or tongue blade and the resulting debris directly applied to a glass slide. Oral swabs are taken if culture is required. Some recommend that swabs be taken from 3 different oral sites.
Treatment of oral thrush starts with treatment of underlying causes and symptoms. oral thrush is treated with topical anti-fungal drugs, such as nystatin, miconazole, Gentian violet or amphotericin B.
Underlying immunosuppression may be medically manageable once it is identified, and this helps prevent recurrence of candidal infection. Prophylactic antifungal therapies are associated with HIV patients or immunocompromised patients who have high risk of the disease. nutrional deficiencies and medical disorders are diagnosed and properly managed.
Special emphasis is given on dentures hygiene like
1) cleaning of dentures with medicated solutions recommended by dentist twice in a day before wearing.
2)taking it out in night time and storing in solution recommended by dentist.
3)regular checkups and follow up at dentist to check for irritating flanges or sharp point on dentures
4)replacement of dentures after they have worn out on recommendation of your dentist.
5)changing the denture cleaning solutions on their expiry.
With proper care and treatment, this disease can be easily avoided.