[Factors related to oral candidiasis in HIV children and adolescents, species characterization and antifungal susceptibility]. / Factores relacionados a candidiasis oral en niños y adolescentes con VIH, caracterización de especies y susceptibilidad antifúngica.

BACKGROUND: Factors associated with candidiasis and colonization in HIV-positive children and adolescents in developing countries are not well understood. AIM: To identify the factors associated with oral Candida colonization and candidiasis in institutionalized HIV-positive children and adolescents in Tijuana, México, as well as the response of the isolates to antifungals. MATERIALS AND METHODS: Sample of the oral mucosa of 30 HIV positive children and adolescents were obtained to isolate and identify Candida species by culture and metabolic profile. Antifungal drugs susceptibility was determined according to CLSI. Indicators of immunological and virologic failure were classified in accordance to WHO criteria. RESULTS: Six Candida species were identified from oral mucosa, 53% colonizers and 47% in candidiasis. Factors associated with candidiasis and oral colonization were viral load (p = 0,001), CD4+ counts (p = 0,002) and HAART regimen (p ≤ 0,014). The most prevalent species was C. glabrata (33%), but C. albicans (27%) was more resistant to fluconazole (p = 0,001). Itraconazol resistant species were identified in regimens that include an NNRTI (p = 0,041). CONCLUSION: HIV-positive children and adolescents living in an orphanage showed high prevalence of colonizing Candida spp. and resistance to antifungals, related to NNRTI.

Factores relacionados a candidiasis oral en niños y adolescentes con VIH, caracterización de especies y susceptibilidad antifúngica / Factors related to oral candidiasis in HIV children and adolescents, species characterization and antifungal susceptibility

Resumen Introducción: Se desconocen los factores asociados a la candidiasis oral en población pediátrica con infección por VIH de los países en desarrollo. Objetivo: Identificar los factores asociados a la colonización por Candida, candidiasis oral y la susceptibilidad in vitro a antifúngicos, en niños y adolescentes con infección por VIH institucionalizados en la ciudad de Tijuana, México. Materiales y Métodos: Se examinó la cavidad oral de 30 niños y adolescentes con infección por VIH, se obtuvo una muestra de la mucosa oral para identificar las especies de Candida mediante cultivo y auxonograma. La susceptibilidad a los antifúngicos se determinó de acuerdo al CLSI. Los indicadores del estado inmunológico y falla virológica se clasificaron conforme a la OMS. Resultados: Se identificaron seis especies de Candida, 53% colonizantes y 47% causantes de candidiasis. Los factores asociados a candidiasis fueron alta carga viral (p = 0,001), menor recuento de LTCD4+ (p = 0,002) y esquema TARAA (p ≤ 0,014). La especie prevalente fue C. glabrata (33%); sin embargo, C. albicans (27%) fue más resistente a fluconazol (p = 0,001). Las especies resistentes a itraconazol se identificaron en esquemas que incluyen un INNTR (p = 0,041). Conclusiones: Los niños y adolescentes con infección por VIH institucionalizados mostraron una prevalencia elevada de Candida spp. colonizante y resistencia a los antifúngicos relacionada con los INNTR .

Background: Factors associated with candidiasis and colonization in HIV-positive children and adolescents in developing countries are not well understood. Aim: To identify the factors associated with oral Candida colonization and candidiasis in institutionalized HIV-positive children and adolescents in Tijuana, México, as well as the response of the isolates to antifungals. Materials and Methods: Sample of the oral mucosa of 30 HIV positive children and adolescents were obtained to isolate and identify Candida species by culture and metabolic profile. Antifungal drugs susceptibility was determined according to CLSI. Indicators of immunological and virologic failure were classified in accordance to WHO criteria. Results: Six Candida species were identified from oral mucosa, 53% colonizers and 47% in candidiasis. Factors associated with candidiasis and oral colonization were viral load (p = 0,001), CD4+ counts (p = 0,002) and HAART regimen (p ≤ 0,014). The most prevalent species was C. glabrata (33%), but C. albicans (27%) was more resistant to fluconazole (p = 0,001). Itraconazol resistant species were identified in regimens that include an NNRTI (p = 0,041). Conclusion: HIV-positive children and adolescents living in an orphanage showed high prevalence of colonizing Candida spp. and resistance to antifungals, related to NNRTI.

Treatment and Prevention of Oral Candidiasis in Elderly Patients.

The incidence of oral candidiasis has increased in the elderly in recent years. Although the increase of the elderly population plays a big role in this rise of oral candidiasis, the broader recognition that elderly people have higher infection rates for oral candidiasis is considered to be also an important factor. Oral candidiasis can be categorized into three types. Pseudomembranous oral candidiasis is characterized by the appearance of white moss, erythematous oral candidiasis by the eruption of erythema, and hyperplastic oral candidiasis by mucosal hyperplasia. Miconazole has been commonly used when treating oral candidiasis. Elderly patients, however, have a tendency to develop oral candidiasis repeatedly. It is therefore critical to take measures to prevent recurrence. We recommend the use an oral moisturizer containing hinokitiol, an antifungal substance, on a regular basis, to help prevent recurrence of oral candidiasis.

Prevalência de candidose bucal em pacientes hospitalizados e avaliação dos fatores de risco / Oral candidiasis prevalence in hospitalized patients and evaluation of risk factors

Introdução: Candida albicans é um fungo que se destaca pela alta frequência de colonização e infecção no hospedeiro humano. É comumente encontrado na cavidade bucal e pode causar infecção em indivíduos que se encontram com deficiência do sistema imunológico ou em portadores de próteses removíveis. Objetivo: realização de um estudo epidemiológico referente à prevalência de candidose bucal em pacientes hospitalizados, avaliando possíveis fatores de risco, como: diabetes, presença de neoplasias malignas e utilização ou não de algum tipo de prótese dentária removível. Metodologia: foram analisados 141 pacientes internados no Hospital da Cidade (HC) no município de Passo Fundo/RS, a fim de avaliar a presença ou ausência de candidose bucal, bem como alguns fatores de risco relacionados a tal enfermidade. Foi feito o exame clínico e, quando possível, realizada a documentação fotográfica dos casos. Os dados coletados foram tabulados em planilha eletrônica e analisados por meio de estatística descritiva de frequência e teste Qui-quadrado ao nível de significância de 5%. Resultados: observou-se que os fatores sistêmicos não apresentaram significância com a presença de candidose (p = 0,726), porém o uso de próteses removíveis (p = 0,042) e o gênero (p = 0,05) apresentaram significância estatística. Conclusão: Na amostra estudada independente de alguns pacientes internados apresentarem doenças sistêmicas (diabetes e/ou neoplasia maligna), não foi notada relação destas com a presença de candidose bucal. Contudo, notou-se que a utilização de próteses dentárias removíveis e o gênero feminino constituem-se como fatores preditivos para a ocorrência de candidose bucal.

Introduction: Candida albicans is a fungus that stands out for the high frequency of colonization and infection in the human host. It is commonly found in the oral cavity and can cause infection in individuals who are disabled or the immune system in patients with removable dentures. Objective: to conduct an epidemiological study regarding the prevalence of oral candidiasis in hospitalized patients, assessing possible risk factors such as diabetes, presence of malignant neoplasms and use or not some kind of removable dental prosthesis. Methods: we analyzed 141 patients admitted to City Hospital (HC) in the city of Passo Fundo/RS, to assess the presence or absence of oral candidiasis, as well as some risk factors related to this disease. Clinical examination was made and, where possible, carried out photographic documentation of cases. Data were tabulated in a spreadsheet and analyzed using descriptive statistics and frequency chi-square test at the 5% significance level. Results: it was observed that the systemic factors were not significant with the presence of candidiasis (p = 0.726), but the use of removable dentures (p = 0.042) and gender (p = 0.05) were considered significant. Conclusion: in the sample studied independent of some hospitalized patients had systemic diseases (diabetes and/or malignancy), was noted their relation with the presence of oral candidiasis. However, it was noted that the use of removable dentures and females constitute as predictors for the occurrence of oral candidiasis (AU)

Differences in impact of patient and prosthetic characteristics on oral health-related quality of life among implant-retained overdenture wearers.

OBJECTIVES: To evaluate the oral health-related quality of life (OHRQoL) of implant-retained overdenture users. METHODS: 63 patients aged 50-90 years treated with at least one implant overdenture at the Complutense University (Madrid) in 2000-2010 were included. Of those, 42 answered the Oral Health Impact Profile (OHIP-14 sp) questionnaire. The additive method was used in the OHIP analysis. Data regarding sociodemographic background, overdenture features, and clinical factors were recorded. Sociodemographic and overdenture-related variables for the lost patients (n=21) were also gathered from their history files. Descriptive probes, Mann-Whitney and Kruskal-Wallis tests, and the Spearman correlation coefficient were applied (p ≤ 0.05). RESULTS: The predominant participants' profile was that of a 71-80-year-old woman wearing a mandibular overdenture with a bar retention system and a complete denture in the opposite jaw. 71.4% of the respondents suffered from some kind of impact on OHRQoL, showing an average score of 2.7 ± 3.0 (range: 0-13). 100% of respondents reported no impact for the "social disability" and "handicap" dimensions. The most prevalently affected domain was "physical pain", followed by "functional limitation" and "psychological discomfort". Variables such as the overdenture location or the retention system affected specific OHIP subscales (p ≤ 0.05). The greatest total score was achieved when the antagonist was a complete denture (p<0.01). CONCLUSIONS: Implant-retained overdentures provide a seemingly acceptable quality of life in the elderly population studied, irrespective of the influence of the location, retention system, and antagonist. CLINICAL SIGNIFICANCE: Although further research is necessary, mandibular implant overdentures are more comfortable than maxillary ones. Ball-retained prostheses facilitate eating the most, whereas the presence of oral ulcers and/or candidiasis was only detected in the case of bars, thus impairing OHRQoL. A complete denture as antagonist decreases the patient overall satisfaction.

Oral candidiasis and angular cheilitis.

Candidiasis, an often encountered oral disease, has been increasing in frequency. Most commonly caused by the overgrowth of Candida albicans, oral candidiasis can be divided into several categories including acute and chronic forms, and angular cheilitis. Risk factors for the development of oral candidiasis include immunosuppression, wearing of dentures, pharmacotherapeutics, smoking, infancy and old age, endocrine dysfunction, and decreased salivation. Oral candidiasis may be asymptomatic. More frequently, however, it is physically uncomfortable, and the patient may complain of burning mouth, dysgeusia, dysphagia, anorexia, and weight loss, leading to nutritional deficiency and impaired quality of life. A plethora of antifungal treatments are available. The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.

Oral fungal infections: an update for the general practitioner.

Oral candidosis is the most common fungal infection encountered in general dental practice. It manifests in a variety of clinical presentations which may mimic more sinister diseases, and can occasionally be refractory to treatment requiring the attention of an oral medicine specialist. Management of oral candidosis should always include a thorough investigation of underlying predisposing conditions, as the disease often presents when the patient is systemically compromised. This update highlights the pathogenesis, clinical presentation, and management strategies of oral Candidal lesions commonly encountered in dental practice.

The role of Candida albicans hyphae and Lactobacillus in denture-related stomatitis.

Denture-related stomatitis (DRS) is still a dilemma in removable prosthodontics. The aim of this study was to investigate the relationship of DRS with the presence of Candida albicans hyphae and Lactobacillus. A total of 91 patients wearing maxillary and mandibular complete dentures were included in the present study and tested mycologically as well as bacteriologically. A statistically significant association of DRS was found with denture age (p = 0.003) and continuous denture wearing (p = 0.015). Presence of C. albicans hyphae was shown to be significantly higher in DRS cases (p < 0.01), and there was a statistically significant positive correlation between presence of hyphae and C. albicans (p < 0.01). Another interesting finding was that DRS patients showed higher Lactobacillus counts in their saliva (p = 0.04), as well as in the palate (p = 0.028). C. albicans is an important factor in the development of DRS. Hyphae seem to facilitate the rise of C. albicans counts and be related to the inflammatory response of the tissues. Lactobacillus seems to play an important role in the presence of DRS, as well. In agreement with many other studies, the results of this study confirm the importance of denture age and continuous denture wearing in the development of DRS.

Mixed Candida albicans and Candida glabrata populations associated with the pathogenesis of denture stomatitis.

INTRODUCTION: Oral yeasts are an important component of the resident microbial ecology of the oral cavity, but they are also associated with various forms of oral candidosis, such as denture stomatitis. Although Candida albicans is the predominant oral fungal pathogen, other species may also play an integral role in pathogenesis. The aim of this study was to examine the mycological ecology in patients with denture stomatitis, using an improved sampling technique, to determine whether species diversity and species quantity were related to oral pathology. METHODS: Thirty-seven patients attending the Glasgow Dental Hospital were enrolled in this study following informed consent. A full clinical history was obtained, including details of their oral hygiene practices and the levels of erythema based on Newton's classification scale. Oral rinse, denture sonicate, and swab samples were taken, which were processed for quantitative and qualitative analysis of oral yeasts. RESULTS: The proportion of patients with no inflammation or Newton's Types I, II, and III were 31, 33, 25, and 14%, respectively. Denture sonication was a superior sampling procedure, with statistically greater quantities of yeasts isolated using this methodology (P < 0.01). The predominant oral yeasts isolated were C. albicans (75%) and Candida glabrata (30%), which were isolated in higher proportions in patients with the highest grades of inflammation (100 and 80%), and in combination from 80% of these patients. CONCLUSIONS: This study has demonstrated that mixed C. albicans and C. glabrata biofilms may play an important role in the pathogenesis associated with severe inflammation in denture wearers.

Oral candidiasis in pediatric HIV patients.

Oral candidiasis can be an early sign of illness or disease progression in HIV/AIDS and other immuno-compromised states. Oral lesions associated with fungal infections present in a variety of forms, including a few of previously unknown etiology. Diagnosing these variants of disease can be challenging because of their atypical clinical presentation. Moreover, the emergence of new candida species, drug resistance and immature immune systems add to the complexity of this condition, especially in children.

Effect of PI-HAART on the prevalence of oral lesions in HIV-1 infected patients. A Greek study.

OBJECTIVE: To investigate the association between the prevalence of oral lesions and highly active antiretroviral therapy (HAART) including a protease inhibitor (PI). DESIGN: Prospective study. PATIENTS AND METHODS: Ninety-five consecutive patients, attending an AIDS Unit, in Greece entered the study. Fourty-four patients were receiving PI- HAART, 14 patients were on double antiretroviral therapy, and 37 patients were not receiving antiretroviral therapy at the time of oral examination. Oral lesions were diagnosed by established presumptive clinical criteria. MAIN OUTCOME MEASURES: Oral lesions were scored. CD4 counts and viral load were determined and related to the prevalence of oral lesions. RESULTS: Oral lesions, and specifically oral candidiasis, were significantly reduced (P < 0.001) in patients receiving PI-HAART. Oral lesions were significantly increased in patients with CD4 counts <200 cells microl(-1) and viral load >20,000 copies ml(-1) (P < 0.001). The percentage of patients, with lesions on PI-HAART, and with CD4 < 200 and viral load >20,000 was 1.5 times lower (37.5%vs 58.8%, P < 0.001) than that of patients not receiving antiretroviral therapy, but with similar immune and viremic status. CONCLUSIONS: Oral lesions were significantly reduced in patients on PI-HAART. A direct anticandidal effect of PI was suggestive and seemed to have accounted, beyond the HAART-related immune reconstitution, for the reduction of candidiasis and all other oral lesions.

The effect of antiretroviral therapy on the prevalence of HIV-associated oral candidiasis in a Spanish cohort.

OBJECTIVE: To investigate the temporal changes in the prevalence of oral candidiasis in a cohort of Spanish human immunodeficiency virus (HIV)-infected individuals, before and after the introduction of highly active antiretroviral therapy (HAART). STUDY DESIGN: Retrospective analysis of a clinical database from "Carlos Haya" Hospital, Málaga, Spain, from 1995 to 2000. The prevalence of oral candidiasis was assessed in 807 HIV/AIDS patients and the temporal progression of its major variants evaluated using a linear regression model. RESULTS: Overall oral candidiasis was prevalent in 30.0% to 48.3% of the cohort throughout and no significant variation in its incidence was noted during the study period. Prevalence of erythematous candidiasis increased from 24.5% (1995) to 45.0% (2000) and pseudomembranous candidiasis decreased from 22.4% (1995) to 5.2% (2000) (P<.05). Hyperplastic candidiasis was not detected in the cohort after the introduction of HAART therapy. CONCLUSIONS: Although oral candidiasis in HIV-infected Spanish individuals has not decreased significantly after the introduction of HAART, there appears to be a significant reduction in hyperplastic and pseudomembranous variants of the disease with a compensatory increase in erythematous candidiasis.

Oral health condition in southern Chinese after radiotherapy for nasopharyngeal carcinoma: extent and nature of the problem.

OBJECTIVE: To measure the oral health status of southern Chinese nasopharyngeal carcinoma (NPC) survivors 1-4 years after radiotherapy. SUBJECTS AND METHODS: A total of 109 subjects participated in this cross-sectional study. Thirty-eight subjects were NPC survivors, 40 subjects were patients newly diagnosed with NPC and 31 were healthy subjects. Verified clinical examination techniques were used to assess limitation of jaw opening, the presence of mucositis, candidiasis, dental caries, periodontal disease [community periodontal index (CPI)] including attachment loss (ALoss) and prosthetic status/need. Differences among three groups were tested by chi-squared and Kruskal-Wallis tests. Relationships between selected clinical variables and radiation parameters were analysed using Spearman's rank correlation coefficients. RESULTS: The NPC survivors attended for dental treatment more frequently than the other groups (P < 0.01). NPC survivors had significant xerostomia (92%, P < 0.01), trismus (29%, P < 0.01), a higher prevalence of clinical candidiasis (24%, P < 0.01), a greater DMFT (16.4 +/- 7.0, P < 0.01), more decay/filled roots (2.1 +/- 2.9, P = 0.01) compared with new NPC patients and controls. No difference was found in CPI, ALoss, prosthetic status and need between groups. Dry mouth and tooth hypersensitivity were the most common oral problems perceived by the NPC survivors. CONCLUSION: Despite having regular dental follow-ups, oral health was compromised in NPC survivors 1-4 years postradiotherapy.

A study on Candida carriage and cytological evaluation of oral mucosa in human immunodeficiency virus (HIV) patients.

This study was undertaken for identification and prevalence of various oral manifestations seen in the oral cavity of HIV infected patients. A quantitative evaluation of candida was done by counting the colony forming units from the oral cavity of HIV infected and non infected individuals. Further, cytopathological changes were evaluated in the oral mucosa of HIV infected patients. Study group consisted of 30 enzyme linked immunosorbent assay (ELISA) confirmed HIV seropositive patients, while the control group consisted of 10 subjects who were HIV negative (by ELISA).

Oral candidosis.

Oral candidosis is the most common opportunistic fungal infection encountered in dentistry. Normally a benign inhabitant of mucous membranes, the fungal organism, Candida albicans, may present serious, even life-threatening infection in specific patient populations. As an opportunistic organism, Candida albicans is extremely responsive to any process resulting in immunosuppression. The clinical manifestations of oral candidosis are variable, occasionally complicating the clinical diagnosis and management. Treatment is often initially rendered based on a provisional clinical diagnosis and supplemented with adjunctive laboratory tests. Specific therapeutic intervention should be tailored to the individual patient, based on the current health status of the patient and the clinical presentation and severity of the infection.

Consensus guidelines on quantifying HIV-related oral mucosal disease.

The workshop agreed that the development of consensus quantification protocols was desirable, but that this whole field was underdeveloped, to date. The working goals were therefore redefined (vide infra). Three possible protocols were presented and discussed relating to oral hairy leukoplakia, oral ulceration (NOS) and oral candidiasis. There was agreement that different data-set protocols would have to be developed for specific HIV-related mucosal diseases. Furthermore, the data set should be consistent, standardized and disaggregated. In this way, with everyone working to the same standards of outcome, data from geographically, nationally, socially or culturally different areas could be readily compared. A future meeting to generate the disease-specific protocols would, most likely, be needed.

Prevalence and classification of HIV-associated oral lesions.

OBJECTIVES: An International Workshop addressed the prevalence and classification of HIV/ AIDS associated oral lesions. DESIGN: Five questions provided the framework for discussion and literature review. What is the prevalence of oral lesions in children and adults? Should the accepted classification of HIV-related oral lesions be modified in the light of recent findings? Why is there a gender difference in the prevalence of oral lesions in developed and developing countries? Are there unusual lesions present in developing countries? Is there any association between modes of transmission and the prevalence of oral lesions? RESULTS: Workshop discussion emphasized the urgent need for assistance in the development of expertise to obtain accurate global prevalence data for HIV-associated oral lesions. Oral candidiasis has been consistently reported as the most prevalent HIV-associated oral lesion in all ages. Penicilliosis marneffei, a newly described fungal infection, has emerged in South-east Asia. Oral hairy leukoplakia and Kaposi's sarcoma appear to be associated with male gender and male-to-male HIV transmission risk behaviours. These lesions occur only rarely in children. CONCLUSIONS: Additional prevalence data are needed from developing countries prior to substantially altering the 1993 ECC/WHO Classification of oral lesions associated with adult HIV infection. The workshop confirmed current oral disease diagnostic criteria.

Differences in risk factors among clinical types of oral candidiasis in the Women's Interagency HIV Study.

OBJECTIVES: The purpose of this study was to determine the prevalence and concurrence/associations of oral candidiasis types and multiple risk factors in women. STUDY DESIGN: A cross-sectional analysis of baseline data for 577 human immunodeficiency virus (HIV)-seropositive and 152 HIV-seronegative women from the Women's Interagency HIV Study was conducted. Pseudomembranous candidiasis (PC) and erythematous (EC) candidiasis, angular cheilitis (AC), and denture stomatitis (DS) were studied, and bivariate and multivariate regression analyses were performed. RESULTS: Prevalences were 8% for PC, 7% for EC, 18% for DS, and 3% for AC; all except AC usually occurred alone. HIV seropositivity was associated with PC, EC, and DS, but not AC. Among HIV-seropositive women, low CD4 cell counts were associated with PC, but not with EC or DS. Heroin/methadone use was associated with PC and EC; salivary hypofunction was associated with PC; high viral load was associated with EC, and poor oral hygiene, with EC and DS. CONCLUSIONS: Risk factors varied among candidiasis types, suggesting differences in pathogenic mechanisms and usefulness as markers of HIV infection/progression.

A systematic review of the management of oral candidiasis associated with HIV/AIDS.

The purpose of this review was to investigate the management of oral candidiasis in HIV/AIDS patients and to evaluate the different guidelines available for its management. A number of topical and systemic antifungal medications are used to treat oral candidiasis in HIV-positive patients. Milder episodes of oral candidiasis respond to topical therapy with nystatin, clotrimazole troches or oral ketoconazole. Fluconazole has been extensively evaluated as a treatment for candidiasis. With HIV-infection, a cure rate of 82% has been achieved with a daily oral dose of 50 mg. Fluconazole was found to be a better choice of treatment for relapsing oropharyngeal candidiasis, resulting in either better cure rates or better prevention of relapse. Intravenous amphotericin B has been found to be effective in azole-refractory candidiasis and is well tolerated. Topical therapies are effective for uncomplicated oropharyngeal candidiasis; however, patients relapsed more quickly than those treated with oral systemic antifungal therapy. Nystatin appeared less effective than clotrimazole and the azoles in the treatment of oropharyngeal candidiasis. Clotrimazole was found to be just as effective for resolution of clinical symptoms as the azoles, except when patient compliance was poor. Fluconazole-treated patients were more likely to remain disease-free during the fluconazole follow-up period than those treated with other antifungal agents.