Antibiotics can worsen oral infection – Expert – Punch Newspapers


Consultant periodontologist at the College of Health Sciences, Obafemi Awolowo University, Osun State, Dr Solomon Nwhator, talks about (oral) thrush, also known as oral candidiasis, in this interview with ALEXANDER OKERE

What is thrush or oral candidiasis?

It is an infection caused by fungi commonly known as yeasts. Hundreds of species of candida exist, the most common being candida albicans. Fungi commonly exist as harmless occupants of the oral cavity and would normally go unnoticed. As harmless occupants in the mouth, they are regarded as commensals. But when an infection arises from these originally harmless commensals, they are termed opportunistic infections.

As long as the balance is maintained in a well-nourished immune-competent individual, no problem arises. This delicate balance could, however, be tilted against the individual when the immunity of the host is reduced or compromised. When this happens, candida overgrows, resulting in the clinical entity known as thrush (oropharyngeal candidiasis).

What are the different types or levels of the infection?

They include acute candidiasis, chronic candidiasis and angular cheilitis.

What are the causes of the infection?

Oral thrush is caused by fungi, most commonly, candida albicans.

Can you tell us the common symptoms?

Most commonly, sufferers would complain about creamy or white-coloured deposits in the mouth. According to the United States Center for Disease Control and Prevention (formerly CDC), the general symptoms of oral candidiasis include white patches on the inner surface of the cheeks, tongue, roof of the mouth and throat. They also include redness or soreness of affected parts, loss of taste, a cotton-like feeling in the mouth, pain experienced while eating or swallowing, cracking and redness at the corners of the mouth.

Are there specific symptoms?

More specifically, different variants of oral candidiasis present with some definitive symptoms and signs. For example, in acute pseudomembranous candidiasis, the dentist or a specialist in oral medicine usually finds white patches typically present on the inner surface of cheeks and lips, the roof of the mouth, the tongue, the gums and the throat. The dentist will usually be able to scrape off this widespread white patch and when this is done, it reveals an underlying red-area that is prone to bleeding.

Unlike the pseudomembranous type, a burning sensation in the mouth or on the tongue usually is the main symptom that heralds acute atrophic candidiasis. The condition might mimic low iron and vitamin B12 levels by presenting with the sign of a bright red tongue. For this reason, it is a little more challenging to diagnosis this variant of oral candidiasis than the acute pseudomembranous type. This is because the soreness of the tongue might be from other causes such as steroids inhalers and prolonged denture wear without adhering strictly to the dentist’s or prosthodontist’s instructions.

In such instances, a swab from the tongue or the inner cheeks surface comes in handy. Unlike the first two classes, chronic hyperplastic candidiasis presents no dramatic symptoms of being easily rubbed off, leaving a bleeding-prone surface. It also does not share the burning or sore tongue symptom of acute atrophic candidiasis. The dentist oral medicine specialist often receives the complaint of a patch on the inner surface of the cheeks or side of the tongue. The white patch here is also much more homogenous and restricted in spread than the acute pseudomembranous variety which stretches all the way down to the throat.

Does acute atrophic candidiasis a reflection of a lifestyle?

Individuals suffering from this type of oral candidiasis are usually smokers. It usually resolves on cessation of smoking but it can progress to a malignancy, hence, it is referred to a candidal leukoplakia, a precursor of malignancy. Also known as “denture stomatitis,” this variant of oral candidiasis commonly occurs in denture wearers, especially in the upper jaw, although the lower jaw could at times be involved also.

It may present with little or no symptoms apart from the fact that it is usually seen as a red area covered by a denture. The diagnosis is simple; once the denture is removed and carefully inspected, but swabs could be taken for microbiology to confirm the diagnosis.

What can you say about median rhomboid glosstis?

Median rhomboid glossitis is an interesting variant of oral candidiasis which for many years was thought to be a developmental condition resulting from failure regression of an embryonic tongue known as the “tuberculum impar.” However, following the finding that almost nine of every 10 cases yield candidal growth on microbiological examination, the current consensus is that it is actually a variant of oral candidiasis. It typically presents as a chronic symmetrical area on the tongue approximately in the eras that demarcate the anterior two-thirds from the posterior one-third of the tongue. This is the same area just anterior to the large papillae called the circumvallate papillae.

In other words, median rhomboid glossitis simply represents an area of loss of smaller tongue papillae called the filiform papillae in association with smoking and steroid inhaler usage. Angular cheilitis is a nutritional deficiency (vitamin B12 deficiency and iron deficiency anemia), an associated variant of oral candidiasis which gives rise to erythematous fissures at the corners of the mouth. The cause is not limited to nutritional deficiency though as it appears to represent a spill-over of oral candidiasis as it is usually associated with a candidal infection in the mouth.

Is candidal infection the only cause of angular cheilitis?

Candidal infection is not the exclusive cause of this condition because staphylococci and streptococci have also been implicated as possible causes of angular cheilitis which, interestingly, could track down from the front of the nostrils to the corners of the mouth. Another interesting twist is the fact that older people could be predisposed to angular cheilitis through their chronically wet fold of skin between the nose and the lip, also called the naso-labial folds. This facial wrinkling is even worse in long-term denture users in which the jaws have grown slightly shorter in height as a result of gradual loss of the tooth-bearing jaw bones.

How can thrush be diagnosed?

Diagnosis of oral pseudomembranous candidiasis is usually straightforward through a microbiological test by culturing a swab from an oral rinse or by staining a smear from the affected area. Some specific variants are named based on location and associated factors, such as the denture stomatitis and the median rhomboid glossitis and angular cheilitis.

What are the risk factors?

Risk factors for thrush include prolonged wearing of dentures especially without following the dentist’s instructions; excessive mouthwash use; dry mouth and malnutrition. Also included are smoking, nutritional deficiencies, impaired salivary gland function from several causes, diabetes mellitus, which can be detected with a simple blood glucose test, anything that alters the normal flora on the mouth, such as prolonged use of broad spectrum antibiotics and steroid aerosol inhalers and psychotropic drugs.

Others are immunosupression and immunosuppressive states like HIV/AIDS as well as immunosuppressive drugs used in the treatment of malignancies, Cushing’s syndrome and malignancies like leukaemia and oral cancer. Those at extremes of age (the very young and very old) and the terminally ill are more vulnerable to thrush.

Are there myths associated with thrush?

One common myth about oral candidiasis is that of attempting relief from the use of antibiotics. This will only worsen the condition! See a dentist or an oral medicine specialist.

 When can the infection be said to be extreme?

Oral candidiasis can be extreme in immune-suppressed persons who could suffer extensive invasion of the oral candidiasis.

 What is the prevalence rate of the infection in Nigeria?

Prevalence figures reported vary from 6.7 per cent to 58.9 per cent in Nigeria. A prevalence of 39 per cent has been reported among healthy schoolchildren in South-East Nigeria. The prevalence of oral thrush yeasts among healthy children in a South-East Nigerian schools was 42.4 per cent among six to seven-year-olds, 33.3 per cent among eight to nine-year-olds year olds and 26.4 per cent among 10 to 11-year-olds. The pattern supports the globally accepted pattern of higher prevalence in younger children.

The prevalence sharply increases with immunosupression with values as high as 80 per cent among HIV-positive Nigerian children. It is noteworthy that the figures reported for healthy children represents those of the yeast with no obvious inform while those among HIV-positive children represent overt clinical infection of oral candidiasis. This supports the known fact that the organism exists as a harmless inhabitant of the mouth but becomes an obvious infection with immunosuppressive conditions like HIV.

What are the different levels of treatment?

Oropharyngeal candidiasis is treated with antifungal medicines with the duration of treatment depending on the severity of the disease. For mild to moderate infections, an antifungal medicine is prescribed to be applied directly to the inside of the mouth as instructed by an oral medicine expert. Different antifungals are usually prescribed for more serious or severe infections as directed by an oral medicine specialist and are usually taken by mouth. Great attention is paid to cases involving the throat.

How easy or affordable is the treatment?

Cost is not the main issue in the treatment of candidiasis. The most important aspect is to investigate the underlying condition. The major cost might be associated with treating the underlying conditions rather than the cost of antifungal.

Are there psychosocial effects of the infection?

There are serious psychosocial effects associated with the infection, especially in persons who fear that they might have some serious immune-suppression.

How can it be prevented?

The prevention of oral candidiasis does not stand alone. It works with the prevention of the predisposing factors and adopting a generally healthy lifestyle.

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