Oral candidiasis

Introduction to oral candidiasis Oral candidiasis (oralcandidiasis) is an oral mucosal disease caused by fungal infections of Candida. In recent years, due to the widespread clinical application of antibiotics and immunosuppressive agents, dysbacteriosis or decreased immunity, resulting in internal organs The incidence of fungal infections in the skin and mucous membranes is increasing, and the incidence of oral mucosal candidiasis is correspondingly increased. Gruby (1842) isolated yeast-like bacteria from the lesions of patients with aphthous ulcers; Berkhont (1923) confirmed that the fungus belongs to the cryptococcal candida, Candida albicans, Candida tropicalis. Among them, Candida albicans is the most important pathogen. Thrush (snow mouth disease) is the most common oral candidiasis. basic knowledge The proportion of sickness: 0.01% Susceptible people: no specific population Mode of infection: non-infectious Complications: sepsis meningitis

Causes of oral candidiasis

25% to 50% of healthy people have oral, vaginal and digestive tracts with Candida, but not onset; non-pathogenic Candida, under certain conditions, can be transformed into pathogenic, so some people call it a rosary The pathogenic bacteria are conditional pathogens. In children with snowy mouth disease, denture stomatitis, angular keratitis, candida leukoplakia and chronic mucosal cutaneous candidiasis, the detection rate of Candida albicans is 84%. 69%, 77%, 84% and 100%.

1. Toxicity and type of pathogen Candida albicans is an oval-shaped yeast-like bacterium, which can produce pseudohyphae in culture medium, tissue and secretion. The bacteria is Gram-positive, 2~3m×4 ~6m, the extended bud cells are very hyphae, so the pseudohyphae, pseudohyphae form blastospores at the nodules, sometimes forming thick-walled spores at the end, and the yeast genus does not form fungal filaments.

The toxicity of Candida depends on the metabolite of toxic substances. The yeast-type Candida parasitic in the digestive tract or vagina is not pathogenic, but when it develops into a mycelial type, it is pathogenic, white. The toxin of Candida has the activity of phospholipase-type A corresponding to the virus, and it can be lethal by injecting the suspension of the bacteria into the vein of the animal. Therefore, the toxicity and type of the pathogen are closely related to the disease power, and the healthy carrier In the middle, the amount of bacteria in the saliva is less than 200/ml. Therefore, the pathogen in the smear cannot be directly found by the general microscopic examination.

Candida albicans has strong adhesion to the oral mucosa epithelium, which is the "foothold" of its pathogenic effect. This adhesion depends on the mannose glycoprotein moiety on the surface of epithelial cells as a surface receptor for cells. By exerting its adhesion, the destruction of glycoprotein or similar structures can inhibit the occurrence of adhesion, which provides a way to explore new therapeutic drugs.

2. Host defense function Human serum contains an anti-fungal component (serum factor), which can inhibit the growth of Candida albicans, which is present in newborn infants (1 to 3 months), but lower than the mother, 6~ Adults can reach adulthood at 12 months, so babies who are half-year-old, especially those who are under full moon, are most susceptible to oral mucosal candidiasis. In addition, neutrophils, monocytes and eosinophils in the human body also have Digest and kill the function of Candida albicans.

3. The influence of drugs and other factors on the body's defense ability The abuse of corticosteroids (SH) often causes Candida infection, SH can weaken the function of the reticuloendothelial system, reduce inflammation and reduce antibody formation; It can increase the activity of fungi, enhance the toxicity of fungi, and the above-mentioned properties of immunosuppressive agents and antimetabolites, thus causing the conditions for the proliferation of fungi.

Broad-spectrum antibiotics can cause dysbacteriosis (such as oral administration of tetracycline for more than 20 days, 2% to 3% of patients with dysbacteriosis), destroy the balance of bacteria and fungi in the human digestive tract, and inhibit certain antifungal effects. The growth of some Gram-negative bacteria and bacteria capable of synthesizing vitamin B; the deficiency of vitamin B group can also inhibit the coenzyme of cell oxidation, reduce the tissue resistance, and thus contribute to fungal growth.

4. Host systemic diseases with congenital immune dysfunction (such as thymus atrophy), receiving larger amounts of X-ray, no gamma-globulinemia, and retinoic system diseases affecting immune function such as lymphoma, He Jiejin Disease, leukemia, etc., are easily associated with candidiasis, abnormal serum iron metabolism is considered to be one of the causes of candidiasis, which may be caused by iron deficiency and cause abnormalities in the body's enzyme system (iron is a cell oxidation-reduction process related enzymes such as peroxidation Enzymes, components of cytochromes) cause defects in immune function.

Low endocrine function, such as hypothyroidism, Edison disease, hypopituitarism, are susceptible to candidiasis.

The pH value of the skin surface of diabetic patients is low, and the sugar content is high, which is conducive to the growth and invasion of Candida albicans. It is also believed that due to the lower fatty acid content of the epidermal keratinized layer of diabetic patients, the ability to inhibit fungi is weakened.

Severe immunodeficiency disease, often associated with oral Candida infection.

5. Other factors Environmental factors and working conditions are related to the pathogenesis of Candida albicans, such as working under high temperature and humidity conditions, prone to skin candidiasis, chronic local irritation, such as dentures, orthodontics, excessive smoking, etc. As a factor of Candida albicans infection, exposure to infection is also an important factor in the pathogenesis. In the maternal baby room, the pathogen can be derived from the maternal vagina, causing thrush in the newborn, due to maternal vaginal infection, newborn within 20 days. The most common cases of cutaneous candidiasis occur in children.

Oral candidiasis prevention

Avoid cross-infection in the delivery room, pay attention to the perineum, birth canal, the hands of the delivery staff and the disinfection of all delivery equipment.

Always wash the baby's mouth with warm water, breastfeeding equipment is boiled and disinfected, and should be kept dry. Before the breastfeeding, the maternal nipple is best washed with 1/5000 hydrochloric acid chlorhexidine solution, and then wiped with cold water.

In winter, children should protect their lips from dryness and cracking, and correct the bad habits of licking their lips.

Patients with long-term use of antibiotics and immunosuppressive agents, or patients with chronic wasting diseases, should be alert to the occurrence of Candida albicans infection, paying particular attention to the complications of deep (visceral) Candida albicans that are easily overlooked.

Oral candidiasis complications Complications sepsis meningitis

If left untreated, it can spread to the throat, digestive tract and respiratory tract, and can be complicated by fungal sepsis, endocarditis, meningitis and other serious complications.

Oral Candidiasis Symptoms Common Symptoms Candida albicans infection debilitating glossitis fungal infection oral mucosal fibrosis irritability irritability dysplasia atypical hyperplasia mucosal congestion pharyngitis, glossitis, gingivitis

The laboratory diagnostic method for candidiasis is currently considered to be the most reliable to form thick-walled spores on corn medium, and the simplest method is direct microscopic examination of specimens.

The dentist often takes the pseudomembrane of the oral mucosa, the epithelium, the sacral shell and other specimens, placed on the glass slide, drops a few drops of 10% potassium hydroxide solution, covers the coverslip, and heats it with micro-fire to dissolve the keratin. Then, a microscopic examination is performed immediately. If a pseudohyphae or a spore is found, it can be confirmed as a fungal infection, but it must be cultured before it can be diagnosed as Candida albicans.

Acute pseudomembranous candida stomatitis should be differentiated from acute cocciditonitis (membrane stomatitis) caused by cocci infections of Staphylococcus aureus, hemolytic streptococcus, pneumococci, and children. Old people are prone to sputum, can occur in any part of the oral mucosa, the area of congestion and edema is obvious, a large amount of fibrinogen exuded from the blood vessels, condensed into grayish white or gray-yellow pseudomembrane, the surface is smooth and dense, slightly higher than the mucosal surface, false The membrane is easily wiped off, leaving erosion surface and oozing, regional lymph nodes, may be accompanied by systemic reactions, smear or bacterial culture to determine the main pathogens.

The main lesions of oral candidiasis can be divided into: candida stomatitis, candida cheilitis and angular cheilitis, chronic mucosal cutaneous candidiasis.

Oral diseases associated with Candida albicans infections include: lichen planus, hairy tongue and median rhomboid glossitis.

1. Candidal stomatitis

(1) acute pseudomembranous type (snow mouth disease): acute pseudomembranous candida stomatitis, can occur in people of any age, but the most common in newborn babies, the incidence rate is 4%, also known as neonatal thrush or Snow mouth disease.

Newborn thrush occurs more than 2 to 8 days after birth. The most common sites are buccal, tongue, soft palate and lip. The mucosa is congested in the damaged area. There are scattered soft spots such as caps and needles. White smudges on the tongue" ("Therapeutic Medicine"); soon merged into white or blue-white velvety patches, and can continue to expand and spread, severe tonsils, pharynx, gums, so that: "full mouth white spots snow flakes Even the pharyngeal edema ("Surgical Authentic"), early mucosal congestion is more obvious, so the contrast between bright red and snow white, and the old lesions mucosal congestion decreased, white patches with pale yellow, patch attachment Not very tight, a little hard to wipe off, exposed red mucosal erosion surface and mild bleeding, children irritability, crying, difficulty breastfeeding, sometimes mild fever, systemic reaction is generally light; but a few cases may spread to Esophagus and bronchus, causing candidiasis esophagitis or pulmonary candidiasis, a small number of patients can also be complicated by children with generalized skin candidiasis, chronic mucosal cutaneous candidiasis.

(2) acute atrophy: acute atrophic candida stomatitis is more common in adults, often due to long-term application of broad-spectrum antibiotics, and most patients have suffered from consumptive diseases such as leukemia, malnutrition, endocrine disorders, After tumor chemotherapy, some skin diseases such as systemic lupus erythematosus, psoriasis, pemphigus, etc., in the process of a large number of penicillin and streptomycin, can also occur candida stomatitis, therefore, this type Known as antibiotic stomatitis, it should be noted that this adult acute candida stomatitis may have a pseudomembrane, accompanied by angular keratitis, but sometimes mainly manifested as mucosal congestion and atrophy of the tongue back nipple, around Thickening of the tongue coating, patients often first taste abnormal or loss of taste, dry mouth, mucous membrane burning.

(3) Chronic hypertrophy: This type or proliferative candida stomatitis can be seen in the buccal mucosa, the back of the tongue and the ankle. As the hyphae penetrate deep into the mucous membrane or the inside of the skin, causing parakeratosis, acanthosis, epithelium Hyperplasia, microabscess formation and inflammatory cell infiltration of the lamina propria, while the surface of the pseudomembrane and epithelial layer are tightly attached, not easy to exfoliate, histological examination, mild to moderate epithelial dysplasia can be seen, some people think that candida White spot disease has a malignant rate of more than 4%, especially elderly patients should be vigilant and seek early biopsy to confirm the diagnosis.

This type of buccal mucosal lesion is often symmetrically located in the inner triangle of the mouth, showing nodular or granular hyperplasia, or a tightly packed white keratinous plaque, similar to the general mucosal leukoplakia. The inflammation develops, the mucosa is papillary hyperplasia; the tongue back lesion can be expressed as filamentous papilla proliferation, grayish gray, called the hair tongue, so the hair tongue is also this type.

Hypertrophic candidiasis can be used as an integral part of the symptoms of chronic mucocutaneous candida disease, as well as in patients with immunodeficiency syndrome and low endocrine function.

(4) Chronic atrophy: This type is also called denture stomatitis. The lesion is often in the side of the maxillary denture. The diaphragm is more common in female patients. (There is a statistical analysis of the incidence of women wearing maxillary dentures. And males are 1/10), the mucous membranes are bright red edema, or yellow-white strips or spotted pseudomembranes, 90% of patients with plaques or pseudomembranes, can be found Candida albicans, Candida 80% of patients with cheilitis or angular cheilitis have dentate stomatitis. Conversely, this type of lesion can often occur alone, not necessarily with lip and mouth.

Tooth stomatitis often occurs simultaneously with mastoid hyperplasia of the upper eyelid. Before considering surgical resection, antifungal therapy should be performed first, which can significantly reduce the degree of hyperplasia and narrow the scope of surgery.

The fungus attached to the denture is the main cause of the disease. For example, it is usually washed with 2% chlorhexidine or nystatin to inhibit fungi. There is an elastic denture base made of silicone rubber which seems to be more easily retained by the adsorption fungus. There are more opportunities for dentin stomatitis.

Fungal stomatitis caused by mandibular dentures is rare. This may be due to the large negative pressure of the maxillary dentures. The antibodies in the saliva are discharged from this area, and the contact between the basal surface and the mucosa is wide and tight. The diseased fungus is stranded.

2. Candidal cheilitis (candidal cheilitis) This disease is chronic cheilitis caused by Candida infection, mostly in high-grade (over 50 years old) patients, usually in the lower lip, can also have candida stomatitis or angular cheilitis .

Gansen divides the disease into two types. The erosive type has a bright red erosive surface in the lower lip and red lips. It is surrounded by keratinization and surface desquamation, so it is easily confused with the discoid lupus erythematosus. Similar to photoactive cheilitis, the granule type is characterized by swelling of the lower lip, and there are often scattered small particles at the junction of the red lips and skin. It is very similar to glandular cheilitis. Therefore, Candida cheilitis should scrape the scales on the edge of the erosion site. Small granular tissue, microscopically detected fungi, such as blastocysts and pseudohyphae, and confirmed by culture to be Candida albicans can be diagnosed.

3. Candidal angular cheilitis (candidal angular cheilitis) This disease is often characterized by bilateral sputum, the skin and mucosa of the mouth area are cleft, adjacent skin and mucous membranes are congested, and there are often erosions and exudates in the cleft palate, or knots. There is a thin sputum, pain or hemorrhage when opening mouth. This kind of fungal keratitis characterized by wet white erosion should be distinguished from vitamin B2 deficiency or bacterial angular keratitis. The former also has glossitis, cheilitis, scrotum or vulvitis. The latter is more common in one side of the mouth, positive for bacterial culture (mainly by streptococcus); and Candida keratitis occurs mostly in children, debilitated patients and patients with blood diseases.

The keratitis of the elderly patients is related to the shortening of the vertical distance of the bite. The skin in the mouth area collapses and is grooved, which causes the saliva to overflow into the ditch from the corner of the mouth. Therefore, it is often in a damp state, which is conducive to the growth and reproduction of mold. 150 cases of denture have been reported. 75 cases of angular keratitis, in addition to the vertical distance shortening and some systemic factors, and the local stimulation of dentures, denture ulcer infection is also closely related.

In the winter when the child is allowed to dry, the keratitis of Candida infection secondary to the dry crack of the lips is also more common.

4. Chronic muco-derma candidiasis (chronic muco-derma candidiasis) This is a special type of Candida albicans infectious disease, the lesions involve oral mucosa, skin and nail bed, mostly from childhood, the disease years to For decades, often accompanied by endocrine or immune dysfunction, cellular immune function is low, so this group of diseases is actually a manifestation of a syndrome, Lehner divided the disease into the following types of causes:

(1) multiple endocrine diseases: often occur before and after puberty, early manifestations of hypoparathyroidism or adrenal insufficiency and chronic corneal-conjunctivitis, but candida stomatitis may be the earliest characterization of the disease.

(2) T lymphocyte deficiency disease type: The disease can be seen in patients with high gammaglobulinemia and malignant lymphoid reticuloma.

(3) Family chronic mucocutaneous Candida: This type can be found in children, but also in adults after 35 years of age (late type), all related to iron absorption and metabolic abnormalities, possibly due to iron rosary The bacterial inhibitory factor is reduced, causing the reproduction and invasion of pathogenic bacteria.

All kinds of chronic mucosal cutaneous candidiasis, the first symptoms are often long-term unhealed or recurrent thrush and angular cheilitis, followed by erythematous desquamation rash on the head and face and limbs, deck thickening, can also occur Baldness and forehead, the skin of the nose is damaged.

Oral candidiasis examination

The laboratory diagnostic method for candidiasis is currently considered to be the most reliable to form thick-walled spores on corn medium, and the simplest method is direct microscopic examination of specimens.

The dentist often takes the pseudomembrane of the oral mucosa, the epithelium, the sacral shell and other specimens, placed on the glass slide, drops a few drops of 10% potassium hydroxide solution, covers the coverslip, and heats it with micro-fire to dissolve the keratin. Then, a microscopic examination is performed immediately. If a pseudohyphae or a spore is found, it can be confirmed as a fungal infection, but it must be cultured before it can be diagnosed as Candida albicans.

Diagnosis and identification of oral candidiasis

Acute pseudomembranous candida stomatitis should be differentiated from acute cocciditonitis (membrane stomatitis) caused by cocci infections of Staphylococcus aureus, hemolytic streptococcus, pneumococci, and children. Old people are prone to sputum, can occur in any part of the oral mucosa, the area of congestion and edema is obvious, a large amount of fibrinogen exuded from the blood vessels, condensed into grayish white or gray-yellow pseudomembrane, the surface is smooth and dense, slightly higher than the mucosal surface, false The membrane is easily wiped off, leaving erosion surface and oozing, regional lymph nodes, may be accompanied by systemic reactions, smear or bacterial culture to determine the main pathogens.

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