Mycotic Diseases and Periodontium

7/28/2019 Mycotic Diseases and Periodontium

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MYCOTIC DISEASES AND PERIODONTIUM


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IntroductionMycoses in healthy individuals are more common in endemic areasthan elsewhere, and they are often asymptomatic and mayspontaneously resolve.

Immunocompromised persons are at particular risk from thesemycoses, and clinical manifestations of infection by these organismsoften 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.


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Oral mycotic diseases can be broadly classified as ORAL CANDIDIASIS (MONILIASIS, THRUSH) NONCANDIDAL/SYSTEMIC ORAL FUNGAL DISEASESo histoplasmosis,o mucormycosis,o cryptococcosis,

o blastomycosis,o coccidioidomycosis, ando aspergillosis,


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ORAL CANDIDIASIS (MONILIASIS, THRUSH)Definition: It is disease caused by infection with yeast like fungusCandida albicans.

Other causative organisms:Candida albicans (yeast & mycelial forms);Candida stellatoidea;Candida tropicalis;Candida parapsillosis;Candida pseudotropicalis;Candida famata;

Candida rugosa;Candida krusei andCandida guilliermondi.


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About oral candidiasis, four major types are recognized:(1) pseudomembranous;(2) hyperplastic;(3) erythematous (atrophic) and(4) angular cheilitis.


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Predisposing factorsAltered local resistancePoor oral hygieneXerostomiaRecent antibiotic treatmentDental applianceCompromised immune system functionEarly infancy

Genetic immune deficiencyAIDSCorticosteriod therapy

PanchytopeniaGeneralized patient debilitationAnaemia, malnutrition, malabsorbtionDiabetes mellitus

Advanced systemic disease


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Clinical featuresIn infantsAge-in neonates, oral lesion starts between the 6th and 10th day afterbirth.

Cause-infection is contracted from the maternal vaginal canal wherecandida albicans flourishes during the pregnancy.Appearance-the lesions in infants are described as soft white or bluishwhite, adherent patches on oral mucosa.

Symptoms-they are painless and notices on careful examinations.


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In adu tSites-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 foodwill cause discomfort, rapid onset of bad taste and there may behistory 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

leaves a normal erythematous area or atrophic area

-deeper invasion by the organisms leaves an ulcerative lesion

u on the removal of the atch


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Histopathological featuresFragments 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.


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Differential diagnosisPlaque form of lichen planus-lesions of thrush can wiped with the

help of gauze.

Leukoplakia-history of recent administration of antibiotics willfavor diagnosis of canadidiasisGangrenous stomatitis-pseudomembrane dirty in color and not

raised above surface

Chemical burns-superficial white burns appear thin and delicate.


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TreatmentRemoval of causesReplacement of denture or relining or applying suspensions below it

while insertion in mouth

The denture must be cleaned throughly and regularly and should beleft out of mouth at night in hypochlorite solution.

Withdrawal or change of antibiotics use if feasible.


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Topical treatment-topical treatments are preferred because they limitsystemic absorption, but the effectiveness depends entirely onpatient compliance.Amphotericin B (Fungizone Oral) Suspension 1 ml swish andswallow QID x 2 weeksClotrimazole (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 suspensionhas 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 "swish andswallow", 4-6 ml.


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Systemic treatmentNystatin 250 mg TDS for 2 week followed by 1 troche per day forthird weekFluconazole 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 sideeffects (gynecomastia in males). Repeated short courses arepreferable. Check drug interactions if patient is on proteaseinhibitors.

Itraconazole 100 mg (200 mg daily orally for 2 weeks)In refractory cases, check to ensure that the causal organism is not

azole-resistant. If discovered to be of mycotic etiology, treat with

Amphotericin B.


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In cases so severe as to interfere with adequate nutrition andhydration, 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 placeone 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. OneMycelex troche dissolved in the oral cavity three times a day hasbeen mentioned to have some efficacy in this regard.


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SYSTEMIC ORAL FUNGAL DISEASESo histoplasmosis,It is also called as Darlings disease.Etiologyo 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 withdropping particularly from infected birds.

Typeso Acute primary histoplasmosiso Progressive disseminated histoplasmosis

o Chronic cavitary histoplasmosis

Oral lesions are common in the progressive disseminated form.


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Age-it is commonly seen in children and elderlySites-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 leftuntreated it will progress to form firm papule or nodules which

ulcerate and slowly enlarge.

Base and surface-ulcerated area covered by non specific graymembrane and is indurated.


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Histopathlogical featuresThe mucosal epithelium shows ulceration, in majority of the cases.

In nonulcerated areas, pseudoepithelliomatous hyperplasia is oftenseen.

The submucosa shows a dense infiltrate of granulocytes,lymphocytes, plasma cells and histocytes.

Multinucleated giant cells and caessation necrosis are often seen.


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Managemento 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 IVPediatric Dose 0.25-1.5 mg/kg/d IV)


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o mucormycosis,It is also called as phycomycosis.Etiology and predisposing factorso 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.TypesoSuperficial

oVisceral-Rhinocerebral or rhinomaxillary formSite-ulcerations of palate, due to necrosis and invasion of palatal

vessels. Ulcer may be seen on gingiva, lip, and alveolar bone.Appearance-it is large and deep, causing denudation of underlyingbone.


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Radiographic featureso Paranasal sinus may reveal mucoperiosteal thickening of the

involved sinus.

o With decrease progression, there is increased nodularity and softtissue thickening, usually mimics a tumor on a radiographicexamination


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Histopathological featuresoThe tissue involved by mucormycosis shows necrosis and chronicinflamatory infiltrate.

o The vessels in the area may be thrombosed with organisms in thelumen.

o The organisms appears as large, nonseptate hyphae with branching atobtuse angle.

o Round and ovoid sporangia are also seen.


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Differential Diagnosiso Squamous cell carcinoma-indurated, longer history, resistance totherapy, firm borders, older patient, biopsy.

o Apthous ulcer-short duration, painful, heals in one to three weeks.


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Managemento Surgical debriment is the treatment choice.o Systemic amphotericin. (Adult Dose 0.3-1.5 mg/kg/d IVPediatric Dose 0.25-1.5 mg/kg/d IV)o Control of predisposing factor such as diabetes.o Elimination ofsecondary infection and symptomatic relief.


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o cryptococcosis,It is also called as torulosis.Etiology and predisposing factorso 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 patientsAge-there is slight predilection for middle aged males.Location-lesion ofhard palate, soft palate, gingiva, extractionsocket, tongue and tonsillar pillar are common.Appearance-they appear as simple nonspecific, single or multiple

ulcers. They are nodular and granulomatous, which may ulcerate

during the course of disease.


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Histopathological featureso In tissue section it appears as a small organisms with a large clearhalo, sometimes described as tissue microcyst

o The tissue reaction is generally granulomatous type; epitheliod cellproliferation is minimal.

o Multinucleated giant cells as well as inflammatory cell infiltrate arecommon.

Diagnosis-the organisms can be cultured on sabourauds glucoseagar.


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Managemento Mild to moderate cases can be treated with ketoconazole for 6 to 12weeks. (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


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o blastomycosis,It is caused by Blastomyces dermatitidis.Etiology and predisposingfactor-organisms is a normal inhabitant

of soil and that is the reason for it to be common in agriculturalworker. It is transmitted through respiratory track.

It may be primary or secondary to some infection elsewhere in thebody.

Typeso Primary pulmonary blastomycosis.

o Cutaneous blastomycosis

o Disseminated or systemic blastomycosis


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Age-it is more common in men than women and typically occursin middle age

Symptoms and signs-oropharyngeal pain, accompanied by theenlargment of cervical lymph nodes, may be presenting sign of oraldisease.

Appearanceo 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.


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Radiographic featureso 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.


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Histopathological featureso The inflammed connective tissue shows occasional giant cells,

macrophages and the typical round organisms, often budding, whenappear to have a doubly refractile capsule.

o Microabcesses are frequently found and if the lesion is not ulceratedoverlying pseudoepitheliomatous hyperplaisa may be prominent.


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Diagnosiso 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 Diagnosiso Squamous cell carcinoma-present for weeks, palpation shows

induration, older patient

o Tuberculosis-undermined flabby borders, usually painless, sputumexamination, mantoux test

o Histoplasmosis-biopsyo Cryptococcosis-organisms culture.Management-amphotericin-B, intravenously for up to 10 weeks


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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 causativeorganisms, Coccidioides immitis.Typeso Primary nondisseminated coccidiodomycosis.

o Progressive disseminated coccidioidomycosis.

ll l


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Age and sex-it is common in all age groups and predominately seenin males.

Incubation period-symptoms occur usually 14 days after inhalationof fungus.Infection is common in summer months, especially after periods ofdust 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 theirclinical appearance.

Healing-these lesions tend to heal by hyalinazation and scarformation.


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Histopathlogical featureso The tissue is similar to any specific granuloma.

o There is accumulation of large mononuclear cells, lymphocytes andplasma cells.

o Foci of coagulation necrosis are often found in the center of smallgranulomas 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.


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Managemento Amphotericin B has been found to be effective Chemotherapeuticagent for the disease. Long-term therapy is required for complete

cure.


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Conclusiono Fungal infections have the potential for serious injury to theperidontium.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 andinvasion and systemic dissemination.


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ReferencesoCarranzas Clinical Periodontology(Newman, Takei and Carranza)o Textbook of Oral Medicine-Anil Govindrao GhomoWeb pages-Oral Diseases And Condition-Dr. Minh Nguyen-Noncandidal Fungal Infetion of the Mouth-Crispian Scully

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Mycotic Diseases and Periodontium