MYCOTIC DISEASES AND PERIODONTIUM

Introduction
Mycoses in healthy individuals are more common in
endemic areas than elsewhere, and they are often
asymptomatic and may spontaneously resolve.
 Immunocompromised persons are at particular risk
from these mycoses, and clinical manifestations of
infection by these organisms often suggest impaired
immune competence.
Patients at greatest risk include those with leukemia,
leukopenia, solid tumors, transplants, or HIV disease.
Also at risk are premature infants.
Oral mycotic diseases can be broadly classified as
 ORAL CANDIDIASIS (MONILIASIS, THRUSH)
 NONCANDIDAL/SYSTEMIC ORAL FUNGAL DISEASES
o histoplasmosis,
o mucormycosis,
o cryptococcosis,
o blastomycosis,
o coccidioidomycosis, and
o aspergillosis,
ORAL CANDIDIASIS (MONILIASIS, THRUSH)
Definition: It is disease caused by infection with yeast
like fungus Candida albicans.
Other causative organisms:
Candida albicans (yeast & mycelial forms);
Candida stellatoidea;
Candida tropicalis;
Candida parapsillosis;
Candida pseudotropicalis;
Candida famata;
Candida rugosa;
Candida krusei and
Candida guilliermondi.
About oral candidiasis, four major types are recognized:
(1) pseudomembranous;
(2) hyperplastic;
(3) erythematous (atrophic) and
(4) angular cheilitis.
Predisposing factors
Altered local resistance
Poor oral hygiene
Xerostomia
Recent antibiotic treatment
Dental appliance
Compromised immune system function
Early infancy
Genetic immune deficiency
AIDS
Corticosteriod therapy
Panchytopenia
Generalized patient debilitation
Anaemia, malnutrition, malabsorbtion
Diabetes mellitus
Advanced systemic disease
Clinical features
In infants
Age-in neonates, oral lesion starts between the 6th and
10th day after birth.
Cause-infection is contracted from the maternal vaginal
canal where candida albicans flourishes during the
pregnancy.
Appearance-the lesions in infants are described as soft
white or bluish white, adherent patches on oral mucosa.
Symptoms-they are painless and notices on careful
examinations.
In adult
Sites-common sites are roof of the mouth, retromalar
area, mucobuccal fold and its common in females as
compared to males.
Symptoms-patient may complain of burning sensation,
spicy food will cause discomfort, rapid onset of bad taste
and there may be history of dryness of mouth.
Signs-Inflammation, erythema and painful eroded areas,
-typical, pearly white or bluish white plaque
-multiple, curdy, loosely adherent patches on any
part of mucosa
-mucosa adjacent to it appears red and moderately
swollen
-white patches of it are easily wiped out with wet
gauze which
Histopathological features
 Fragments of plaque material may smear on a
microscopic slide, macerated with 20 percent potassium
hydroxide and examined for hyphae.
 Presence of yeast cells are examined for hyphae or
mycelia in the superficial and deeper layer of involved
epithellium.
 The submucosa may contain chronic inflammatory cell
infiltrate.
Differential diagnosis
Plaque form of lichen planus-lesions of thrush can
wiped with the help of gauze.
Leukoplakia-history of recent administration of
antibiotics will favor diagnosis of canadidiasis
Gangrenous stomatitis-pseudomembrane dirty in
color and not raised above surface
Chemical burns-superficial white burns appear thin
and delicate.
Treatment
Removal of causes
Replacement of denture or relining or applying
suspensions below it while insertion in mouth
The denture must be cleaned throughly and regularly
and should be left out of mouth at night in hypochlorite
solution.
Withdrawal or change of antibiotics use if feasible.
Topical treatment-topical treatments are preferred
because they limit systemic absorption, but the
effectiveness depends entirely on patient compliance.
Amphotericin B (Fungizone Oral) Suspension 1 ml
swish and swallow QID x 2 weeks
Clotrimazole (Mycelex troches) dissolved in mouth 5
times/day x 2 weeks, or until plaques clear.
Swish, retain in mouth as long as possible, then swallow.

Recommeded therapy is for two weeks. Note that

oral suspension
has a high sugar content, which may precipitate caries
or xerostomia.

Alternative therapy-Nystatin vaginal pastilles

dissolved in mouth are
very effective, or may use Nystatin oral suspension
 troche per day for third week
Fluconazole 100 mg QD X 14 days.

Ketoconazole 200mg, 1 tablet QD for 2 weeks.

Instruct patient to
take with acidic liquids (orange juice), and not with
food. Long-
term therapy with ketoconazole is not recommended
due to side
effects (gynecomastia in males). Repeated short
courses are
preferable. Check drug interactions if patient is on
protease
inhibitors.

Itraconazole 100 mg (200 mg daily orally for 2 weeks)

In refractory cases, check to ensure that the causal

organism is not
 In cases so severe as to interfere with adequate
nutrition and hydration, patient may require
hospitalization for hydration and nutritional support.
 In patients who wear partials or dentures, have them
soak the prosthesis in chlorhexidine solution (such as
PerioGard), then place one ml of amphotericin B
suspension on the acrylic portion of the appliance
before reinserting into the mouth. This will prevent re-
infection by the appliance.
 Maintenance therapy for future suppression may be
necessary. One Mycelex troche dissolved in the oral
cavity three times a day has been mentioned to have
some efficacy in this regard.
SYSTEMIC ORAL FUNGAL DISEASES
o histoplasmosis,
It is also called as Darling’s disease.
Etiology
o It is caused by Histoplasma capsulatum, a dimorphic
fungus that grows in the yeast form in infected tissue.
o Infection results from inhalation of dust contaminated
with dropping particularly from infected birds.
Types
o Acute primary histoplasmosis
o Progressive disseminated histoplasmosis
o Chronic cavitary histoplasmosis
Oral lesions are common in the progressive
Age-it is commonly seen in children and elderly

Sites-it is seen on buccal mucosa, gingiva, tongue,

palate or lip.

Symptoms-patient may complain of sore throat, painful

chewing, hoarseness, difficulty in swallowing.

Appearance-oral lesion are nodular, ulcerative or

vegetative. If left untreated it will
progress to form firm papule or nodules which ulcerate
and slowly enlarge.

Base and surface-ulcerated area covered by non

Histopathlogical features
The mucosal epithelium shows ulceration, in majority of
the cases.
In nonulcerated areas, pseudoepithelliomatous
hyperplasia is often seen.
The submucosa shows a dense infiltrate of granulocytes,
lymphocytes, plasma cells and histocytes.
Multinucleated giant cells and caessation necrosis are
often seen.
Differential Diagnosis
o Tuberculosis-sputum examination, tuberculin test.
o Blastomycosis-biopsy and culturing the organisms
from tissue.
o Mucormycosis-biopsy.
o Cryptococcosis-organisms cultured on Sabouraud’s
glucose agar.
Management
o Ketoconazole-6 to 12 months (Adult Dose 200-400
mg/d PO, with food or soda Pediatric Dose 5-10
mg/kg/d PO)
o Severe form-Amphotericin B, IV. (Adult Dose 0.3-
1.5 mg/kg/d IV Pediatric Dose
0.25-1.5 mg/kg/d IV)
o mucormycosis,
It is also called as phycomycosis.
Etiology and predisposing factors
o It is caused by saprophyte fungus.
o More common in patients with decreased resistance,
due to diseases like diabetes, tuberculosis, renal failure,
leukaemia, cirrhosis and in severe burn cases.
 Types
o Superficial
o Visceral-Rhinocerebral or rhinomaxillary form
Site-ulcerations of palate, due to necrosis and invasion
of palatal vessels. Ulcer may be seen on gingiva, lip,
and alveolar bone.

Radiographic features

o Paranasal sinus may reveal mucoperiosteal thickening of

the involved sinus.

o With decrease progression, there is increased nodularity

and soft
tissue thickening, usually mimics a tumor on a
radiographic
examination
Histopathological features

oThe tissue involved by mucormycosis shows necrosis

and chronic
inflamatory infiltrate.

o The vessels in the area may be thrombosed with

organisms in the
lumen.

o The organisms appears as large, nonseptate hyphae

with branching at
obtuse angle.

o Round and ovoid sporangia are also seen.

Differential Diagnosis
o Squamous cell carcinoma-indurated, longer history,
resistance to therapy, firm borders, older patient,
biopsy.
o Apthous ulcer-short duration, painful, heals in one to
three weeks.
 Management
o Surgical debriment is the treatment choice.
o Systemic amphotericin. (Adult Dose 0.3-1.5
mg/kg/d IV Pediatric Dose 0.25-1.5
mg/kg/d IV)
o Control of predisposing factor such as diabetes.
o Elimination of secondary infection and
symptomatic relief.
o cryptococcosis,
It is also called as torulosis.
Etiology and predisposing factors
o It is a chronic fungal infection caused by Crptococcus
neoformans and Crptococcus
bacillispora.
o infection occurs due to inhalation of air borne
microorganisms.
o it has increased incidence in immunosupressive
patients
 Age-there is slight predilection for middle aged males.
Location-lesion of hard palate, soft palate, gingiva,
extraction socket, tongue and tonsillar pillar are
common.
Histopathological features
o In tissue section it appears as a small organisms with a
large clear halo, sometimes described as tissue
microcyst
o The tissue reaction is generally granulomatous type;
epitheliod cell proliferation is minimal.
o Multinucleated giant cells as well as inflammatory cell
infiltrate are common.
Diagnosis-the organisms can be cultured on
sabouraud’s glucose agar.
Management
o Mild to moderate cases can be treated with
ketoconazole for 6 to 12 weeks. (Adult Dose 200-
400 mg/d PO, with food or sodaPediatric Dose 5-10
mg/kg/d PO)
o The severe form requires amphotericin-B,
intravenously for up to 10 weeks
o blastomycosis,
It is caused by Blastomyces dermatitidis.
Etiology and predisposing factor-organisms is a
normal inhabitant of soil and that is the reason for it to
be common in agricultural worker. It is transmitted
through respiratory track.
It may be primary or secondary to some infection
elsewhere in the body.
Types
o Primary pulmonary blastomycosis.
o Cutaneous blastomycosis
o Disseminated or systemic blastomycosis
Age-it is more common in men than women and
typically occurs in middle age
Symptoms and signs-oropharyngeal pain,
accompanied by the enlargment of cervical lymph
nodes, may be presenting sign of oral disease.
Appearance
o Nonspecific, painless verrucous ulcer with indurated
borders often mistaken for squamous cell carcinoma.
o Other lesions are hard nodules and appear as sessile
projection, granulomatous appearing plaque.
Radiographic features
o Radiographs may show periostitis and subperiosteal new
bone formation.
o Oteoblastic reaction is usually present in later stages of
disease.
o Chest radiograph shows concomitant pulmonary
involvement in most of the cases.
Histopathological features
o The inflammed connective tissue shows occasional giant
cells, macrophages and the typical round organisms,
often budding, when appear to have a doubly refractile
capsule.
o Microabcesses are frequently found and if the lesion is
not ulcerated overlying pseudoepitheliomatous
hyperplaisa may be prominent.
Diagnosis
o The index of suspicion increases when chronic, painless,
oral ulcer appears in an agricultural worker or when
review of system reveals pulmonary symptom.
o Diagnosis is made on the basis of biopsy and on
culturing the organisms from tissue.
Differential Diagnosis
o Squamous cell carcinoma-present for weeks,
palpation shows induration, older patient
o Tuberculosis-undermined flabby borders, usually
painless, sputum examination, mantoux test
o Histoplasmosis-biopsy
o Cryptococcosis-organisms culture.
Management-amphotericin-B, intravenously for up to
o coccidioidomycosis
It is also called valley fever, desert fever or
coccidiodal granuloma.
Etiology-the disease appear to be transmitted to man
and animals by inhalation of dust contaminated by
spores of the causative organisms, Coccidioides
immitis.
Types
o Primary nondisseminated coccidiodomycosis.
o Progressive disseminated coccidioidomycosis.
Age and sex-it is common in all age groups and
predominately seen in males.

Incubation period-symptoms occur usually 14 days

after inhalation of fungus.

Infection is common in summer months, especially after

periods of dust storm. It is self limiting and runs its course
within 10 to 14 days.

Apperance-the lesions of oral mucosa and skin are

proliferative, granulomatous and ulcerated lesions that
are nonspecific in their clinical appearance.

Healing-these lesions tend to heal by hyalinazation and

scar formation.
Histopathlogical features
o The tissue is similar to any specific granuloma.
o There is accumulation of large mononuclear cells,
lymphocytes and plasma cells.
o Foci of coagulation necrosis are often found in the
center of small granulomas and multinucleated giant
cells are scattered throughout lesion.
o The organisms is found within the cytoplasm of giant
cells, as well as is lying free in the tissue.
Management
o Amphotericin B has been found to be effective
Chemotherapeutic agent for the disease. Long-term
therapy is required for complete cure.
Conclusion
o Fungal infections have the potential for serious injury to
the peridontium.
o The oral lesions associated with these deep fungal
infections are chronic, may mimic neoplasms, and
progress to form solitary, chronic deep ulcers with the
potential for local destruction and invasion and systemic
dissemination.
References
o Carranza’s Clinical Periodontology(Newman,
Takei and Carranza)
o Textbook of Oral Medicine-Anil Govindrao Ghom
oWeb pages
-Oral Diseases And Condition-Dr. Minh Nguyen
-Noncandidal Fungal Infetion of the Mouth-Crispian
Scully