May 14, 2024/ Candidal Infection Dr. Darya K.

Mahmood

Candidiasis( also called moniliasis) is the most common oral fungal infection in human
and it has a variety of clinical manifestations. Candida albicans a yeast-like fungus may be a
component of the normal oral microflora. Three general factors may determine the evidence of
the infection:

1- The immune status of the host

2- The oral mucosa environment ( changes in oral flora by antibiotic, xerostomia)
3- The strain of C.albicans
Candidiasis of oral mucosa may exhibit a variety of clinical patterns:

1- Oral thrush (pseudomembranous candidiasis)

Thrush is a disease recognized in infants and adults. Neonatal type results from
immaturity of the immune response, infection are probably acquired during passage through
the birth canal. Thrush (adult type) may be initiated by exposure of the patient to broad-
spectrum antibiotics or by impairment of patient immune system. Any adult male who develops
thrush without apparent cause should be suspected of having HIV infection.

Clinical features;

Thrush forms soft, friable, white plaques that resemble cottage cheese or curdled milk on
the oral mucosa, the white plaque is composed of tangled masses of hyphae, desquamated
epithelial cells and debris. The distinctive feature is that they can be easily wiped off, to expose
an erythematous mucosa. The plaque is mainly found on buccal mucosa, palate, and dorsal
tongue. Symptoms are usually relatively mild, consisting of a burning sensation of oral mucosa
or unpleasant taste.

2-Erythematous candidiasis: several clinical presentations

A-Acute atrophic candidiasis (antibiotic sore mouth): This can follow overuse or topical, oral
use of antibiotics (broad-spectrum antibiotic), especially tetracycline suppressing normal
competing oral flora.

Clinically, patients often complain that their mouth feels as hot beverage had scaled them. The
whole mucosa is red and sore with diffuse loss of the filiform papillae of dorsal tongue.
Resolution may follow withdrawal of the antibiotic but is accelerated by topical antifungal
treatment.

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May 14, 2024/ Candidal Infection Dr. Darya K. Mahmood

B-Median rhomboid glossitis (central papillary atrophy); chronic candidal infection of the
tongue. In the past, it was thought to be a developmental anomaly. Clinically: appear as an
asymptomatic well-demarcated erythematous zone that affects the midline, posterior dorsal
tongue. The erythema is due to loss of filiform papillae in this area, usually symmetric; the
surface ranged from smooth to lobulated.

C-Angular stomatitis (angular cheilitis): is typically caused by leakage of candida infected saliva
at the angles of the mouth. It can be seen in infantile thrush, in denture wearers or association
with chronic hyperplastic candidosis.

Clinically; there is mild inflammation at the angles of the mouth characterized by erythema,
fissuring, and scaling. In elderly patients with the reduced vertical dimension of occlusion,
accentuated folds at the corners of the mouth, then saliva tends to pool in these areas keeping
them moist and favoring fungal infection.

D-Denture-induced stomatitis (chronic atrophic candidiasis)

Clinically: this condition is characterized by varying degree of erythema, sometimes

accompanied by petechial hemorrhage, localized to the denture–bearing areas of a maxillary
removable denture. Usually, patients are wearing the denture continuously. Whether this
represents actual infection by C.albicans or it is simply a tissue response by the host to various
microorganisms beneath the denture remains controversial, or a reaction to improper design of
the denture and allergy to denture base.

Diagnosis; if the palatal mucosa or contact surface of denture swabbed and streaked on agar, it
shows heavy colonization of candidal infection.

3-Chronic hyperplastic candidiasis (candidal leukoplakia) it classically presents as a white patch

on the commissures of the oral mucosa, it cannot be removed by scraping. It is the least common
type of candidiasis and somewhat controversial. As it may arise from candidal infection that is
superimposed on preexisting leukoplakia, or a candidal infection alone may be capable of
inducing hyperkeratotic lesions.

Clinically, Affect adults, typically male of middle age or over. The usual site is anterior buccal
mucosa and cannot be clinically distinguished from routine leukoplakia. The plaque is variable

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May 14, 2024/ Candidal Infection Dr. Darya K. Mahmood

in thickness and often rough or irregular in texture, or nodular with an erythematous

background (speckled leukoplakia) such lesions may have increased frequency of epithelial
dysplasia.

Histopathological features of candidal infection:

The candidal organism can be seen microscopically in either an exfoliative cytological

preparation or in tissue sections obtained from a biopsy. Staining with periodic acid shift stain
(PAS) is used to identify candidal hyphae. The histopathological pattern of oral candidiasis may
vary depending on which clinical form of infection submitted for biopsy. The features that are
found in common include:

1. Increase thickness of parakeratin on the surface of the lesion,

2. Elongation of epithelial rete ridges,

3. Chronic inflammatory cell infiltrate the connective tissue immediately subjacent to

infected epithelium,

4. Small collections of neutrophisl are often identified in the parakeratin layer and
superficial spinous cell layer,

5. Candidal hyphae are embedded in the parakeratin layer and rarely penetrate the viable
cell layers of epithelium.

The treatment of candidiasis is based in the use of topical polyene (nystatin or

amphotericin) or azole antifungal agents (clotrimazole, miconazole, ketoconazole, fluconazole
or itraconazole). The drug chosen depends on the clinical history of the patient, the oral
symptoms and compliance.