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Candida Albicans Colonization, Role and Effects of This Opportunistic Pathogen On Orthodontic Appliances PDF
Candida Albicans Colonization, Role and Effects of This Opportunistic Pathogen On Orthodontic Appliances PDF
Corresponding Author:
Dr. Francesca Muggiano,
Dentist, Dipartimento di Scienze Odontostomatologiche e Maxillo Facciali, Universita' degli Studi di Roma - Italy
Submitting Author:
Dr. Francesca Muggiano,
Dentist, Dipartimento di Scienze Odontostomatologiche e Maxillo Facciali, Universita' degli Studi di Roma - Italy
Other Authors:
Dr. Andrea Quaranta,
Dentist, Dipartimento di Scienze Odontostomatologiche e Maxillo Facciali, Universita degli Studi di Roma - Italy
Dr. Michele Previati,
Dentist, Azienda Sanitaria Regione Molise, Campobasso, Italy - Italy
Competing Interests:
No competing interests.
● Rate of removal = rate of acquisition and growth → that moderate stress may affect the process of
colonization. microbial colonization and the adherence of this
● Rate of removal <rate of acquisition and growth (and yeastto epithelial cells by altering the secretory activity
there is tissue damage)→candidiasis.
of salivary glands. Because adherence is an important
In the table I are listed several factors that influence virulence factor in Candida, the inhibition of this
candidiasis and colonization of the oral cavity by process is an important strategy in the prevention of
Candida albicans. oral candidosis. Itsantigens, host proteins, antifungal
agents and antibodies have been used to inhibit
1. Acquisition: in humans, Candida albicans
Candida albicansadherence to host cells. IgA seems
preferentially colonizes mucosal surfaces, and the
to play an important role by causing fungal
intestinal tract is believed to be a major reservoir for
aggregation and preventing the adherence to mucosa
infection (Odds, 1988; Cole et al., 1996). Candida
or oral surfaces.
albicans can colonize practically any site in the
gastrointestinal tract, from the oral cavity to the rectum 4. Growth: In order to maintain Candida populations in
and peri-anal tissues, allowing anal-oral inoculation to the oral cavity, cells must grow and multiply at a rate
occur (Soll et al., 1991). This yeast survives better on at least equal to that of clearance. Anymetabolic
moist surfaces than dry inanimate objects, but if the activity that helps this yeast acquire carbon or nitrogen
degree of contamination is high enough, viable cells will aid its growth and survival in the oral cavity.
will remain on dry surfaces for at least 24 hours. Competition with other oral micro-organisms
Candida species can enter in the oral cavity by manual for nutrients, such as glucose, affects the growth rate
inoculation, saliva transfer, or contaminated food and of Candida cells. It is recognized that antibiotic
drink. treatment, which reduces the number of oral bacteria,
is a predisposing factor for oral candidiasis
2. Maintaning an oral Candida population: the entry of
(Samaranayake, 1990). Oral bacteria are present in
Candida cells into the oral cavity is not sufficient for
most oral sites at concentrations much higher than
colonization, but they must be stably maintained.
Candida albicans, and so the Candida cells must
Since the oral cavity is a continuous-flow environment,
compete with them for adhesion sites and nutrients,
yeast cells will be washed out by saliva and swallowed
and be exposed to bacterial toxins and byproducts.
unless they adhere and replicate. Adhesion is
therefore of critical importance in colonization and it is 5. Evading host clearance mechanisms: immune
mediated between moieties of the Candida cell wall system defects are a major risk factor for candidiasis.
and host surfaces. Innate defenses include the epithelial barrier and
anti-candidal compounds in saliva (such as lysozyme,
3. Adherence to oral surfaces: Candida albicans can
histatins, lactoferrin, and calprotectin). Acquired
adheres in a number of surfaces in the oral cavity
immunity includes the production of immunoglobulins
(buccal epithelial cells, inert polymers of dental
and, if tissues are penetrated, the involvement
prostheses, teeth, and other oral micro-organisms).
of macrophages and polymorphonuclear leukocytes.
Colonization may contribute to the deterioration of the
The major immunoglobulin in saliva is secretory IgA.
oral devices. This yeast showed a great adherence to
acrylic and adherence is increased on rough acrylic As already said, the primary etiological agent of oral
and silicone rubber surfaces compared with smooth candidiasis is the yeast Candida albicans; however,
surfaces (Verran and Maryan, 1997). The acrylic base other species that cause disease less commonly
for dentures supported less adherence of C. albicans include Candida tropicalis, Candida glabrata, Candida
than tissue conditioners and a soft liner (Okita et al., krusei, Candida parapsilosis, Candida guilliermondii
1991). and Candida dubliniensis.
Many factors may influence the process of adherence Among the many factors that contribute to the higher
to oral epithelial cells (Tabel II). prevalence of Candida albicansin the oral cavity are its
excellent ability to adhere and the presence of many
The effects of these components on the adherence of
cell receptors, which confer versatility and resistance
Candida albicans differ: some of them increase the
to removal by the fluids that bathe these surfaces.
adhesion capacity, whereas others show inhibitory
activity. Biasoli et al. observed a correlation between Adhesion and colonization of the oral cavity by
the capacity for yeast to adhere and its ability to Candida albicansis an initial step in candidosis. The
colonize mucosal surfaces. Candida presents the pathogenicity of Candidaspp. is due to enzyme
highest values of adherence to oral epithelial cells production, tissue invasion, and their capacity to
relative to other Candida species. Boshet al. verified adhere to oral mucosa.
Orthodontic and other oral appliances seem to favor evaluate whether metal ions affect fungal virulence.
candidal presence, so we will analyze the relationship The results revealed that all ions, except Co++,
between this yeast and orthodontic patients. The caused increases in biofilm biomass. Their results
presence of orthodontic and other oral appliances indicate that metal ions released during the
seems to alter the oral ecological environment. Hence, degradation of orthodontic appliances can modulate
these appliances may tip the balance to favour the virulence factors in C. albicans biofilms.
existence of Candida species.Biofilms on removable Therefore, during orthodontic treatment, it is important
orthodontic appliances act as reservoir of to minimize colonization to prevent active infection that
microorganisms, capable of modifying the could consequently interfere with treatment. Hygiene
environmental condition of oral cavity and are difficult is the most important factor in managing colonization.
to be removed with routine hygiene measures. In their study, Decelis et al. (2012) tested the efficacy
Topaloglu-Ak et al. (2011) showed that mutans and of NitrAdine to reduce Candida and they concluded
Lactobacillus sp. counts increased significantly 6 that it may reduce the Candida burden in maxillary
months after the insertion of fixed/removable removable appliances. Carvalhinho et al. (2012)
orthodontic appliances in the oral cavity. A significant analyzed the susceptibilities to antifungal agents
increase for Candida albicans presence was noted (fluconazole, econazole, miconazole and ketoconazole,
after 3 months compared with baseline for fixed amphotericin B and nystatin), mouth rinses and
appliances. Long-term utilization of orthodontic essential oils of patient's mouth with fixed
appliances may have a negative effect on microbial orthodontic appliances. The results showed that all
flora and increase the risk of new carious lesions and isolates tested were susceptible to amphotericin B,
periodontal problems. nystatin and fluconazole; one isolate was resistant to
Silva et al. (2013) compared the presence of econazole (2.5%) and the other to ketoconazole
Candidaspecies in saliva and the levels of anti- (2.5%). Econazole and ketoconazole had the highest
Candida albicansIgA in children with or without percentages of susceptible dose dependent (SDD), 55
orthodontic appliances. The results showed that and 95%, respectively. The study of mouth rinses
Candida albicansis the species most frequently showed a high variability of efficacy against C.
isolated from the oral cavities of patients in both albicans. The results showed that the isolates
groups, followed by Candida tropicalis. No correlation susceptibility to essential oils differed. The profile
was observed between the level of activity was: cinnamon > laurel > mint > eucalyptus
anti-Candidaalbicans IgA in saliva and the presence of > rosemary > lemon > myrrh > tangerine. The
this yeastor its adherence to epithelial cells. In this susceptibility of econazole-SDD isolates to cinnamon
study, the quantity of IgA was low in children of both and lemon was higher than those of the econazole-S
the experimental group (who were users of removable yeasts. In contrast, econazole-SDD isolates were less
orthodontic appliances for at least 6 months) and the affected by laurel than econazole-S counterparts.
control group (who were not users of any orthodontic
appliances). Salivary IgA generally increases with age Results and Conclusions
because the secretory immunological mechanism
develops simultaneously with the humoral immune
system. In patients with dental prosthesis or The limited amount of literature demonstrated that the
removable orthodontic devices, salivary IgA reduces density of Candida increases; the most
the adherence of Candida albicansto polystyrene. common Candida species isolated in the orthodontic
Their results indicate that anti- Candida albicansIgA is patients is Candida albicans and that there seems to
not the most important factor to determine be a direct relationship between the presence of a
Candidacarrier status. removable appliance, Candida and low salivary pH
Hence, Candida colonization is a consequence levels. It is important to emphasize that no healthy
of orthodontic treatment and can lead to oral patients developed Candida infection from the
candidosis as a complication of removable appliance orthodontic appliances. However, there seems to be a
treatment. The installation of metal devices leads to an trend that some non-Candida carriers converted
increase in the salivary concentration of metal ions to Candida carriers following the insertion of the
and in the growth of salivary Candida spp. Ronsani et appliances by unknown mechanism. This may indicate
al. (2011) examined the relationship between released a more cautious approach when providing orthodontic
metal ions (Ni++, Fe+++, Cr+++, Co++ or a mixture of treatments to immunocompromised children
these metal ions) and Candida virulence, in order to concerning the possible increased risk of candidal
Illustrations
Illustration 1
Table I: Factors that influence candidiasis and colonization of the oral cavity.
Candidiasis Colonization
Tissue colonized Acquisition (entry of cells into the oral cavity)
Virulence factors expressed by the Candida cells Attachment and growth of cells
Host response Penetration of tissues
Removal of cells from he oral cavity
Illustration 2
Table II: Factors that influenced the adherence of Candida to oral epithelial cells