•Leukoplakia
•Hairy leukoplakia
•Lichen planus
•Lupus erythematosus
•Mucous patches of secondary syphilis
•White sponge nevus
•Uremic stomatitis
•Cinnamon contact stomatitis
•Chemical burns
•Traumatic lesions
•Furred tongue
Basic Guidelines
•Elimination of systemic and/or local predisposing factors are important to avoid recurrences.
•Maintenance of high level of oral hygiene and reduction of the Candida reservoir in the mouth, esophagus, and genitalia.
•Accurate diagnosis of the clinical form of oral candidiasis is important.
•Topical or systemic therapy should be used depending on the form and severity of the disease.
•The majority of the available antifungal drugs target the synthesis of ergosterol. a constituent of the fungal cell membrane.
Suggested Therapies
Systemic Treatment
Systemic azoles are the drugs of choice. Itraconazole capsules 100 mg/day or fluconazole 100 mg/day for 1-2 weeks are usually effective for acute pseudomembranous candidiasis and Candida-associated lesions. The erythematous and nodular forms usually need therapy for 2-4 weeks. The secondary forms need long-term administration of the above drugs in a close of 100-200 mg/day for 1-3 months.
Ketoconazole capsules 200 mg twice daily for 1-4 weeks, depending the form of the disease, may also be used. In patients with resistant Candida species, in neutropenic patients, or in patients with malignancies, transplants, and AIDS, itraconazole oral solution 2.5-5 mg/kg per day is indicated. Ketoconazole has significantly greater bioavailability than itraconazole and, in addition, has a topical effect; therefore it may convey additional benefits over other oral agents in the treatment of oral candidiasis. It must be remembered that successful systemic treatment of oral candidiasis often depends on correction or treatment of the predisposing factors.
The use of systemic azole derivatives can be impaired by interference with gastric pH. by interactions with other drugs such as rifampicin, acyclovir, cyclosporine. phenytoin. H2-antagonists, terfenadine. astemizole. or by the emergence of resistant or less susceptible strains of Candida.
Clinicians should avoid systemic azoles in patients with severe liver disease and during pregnancy. The most frequent side effects of itraconazole and fluconazole are gastrointestinal symptoms (nausea, vomiting, diarrhea, epigastralgia)and rash.
Topical Treatment
Nystatin oral suspension four times a day or miconazole oral gel 5 ml four times a day for 1-2 weeks is indicated, particularly for oral acute pseudomembranous candidiasis in infants or children or for adults where systemic treatment is not indicated. Angular cheilitis (perlèche) is treated with topical antifungal ointments.
Future Therapies
Third generation triazoles (voriconazole, posa-conazole. ravuconazole), echinocandins (main representative caspofungin) and the incorporation of nystatin into liposomes are being investigated as possible alternative treatments.
References
Davies A, Brailsford S, Broaclley K, Beighlon D. Resistance amongst yeasts isolated from the oral cavities of patients with advanced cancer. Patiiat Med 2002;16:527–531.
Dismukes WE. Introduction to antifungal drugs. Clin Infect Dis 2000;30:653–657.
Ellepola ANB, Samaranayake LP. Antimycotic agents in oral candidosis: An overview: 2. Treatment of oral candidosis. Dent Update 2000;27;165–174.
Epstein JB, Gorsky M, Caldwell J. Fluconazole mouthrinses for oral candidiasis in postirradiation, transplant, and other patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:671–675.
Fratti KA, Belanger PH, Samari H. The effect of the new triazole, voriconazole (UK-109, 496) on the interactions of Candida albicans and Candida krusei with endothelial cells. J Chemother 1998;10:7–16.
Goins RA, Ascher D, Waecker N, et al. Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants. Pediatr Infect Dis J 2002;21:1165–1167.
Groll AH, Wood L, Roden M, et al. Safety, pharmacokinetics, and pharmacodynamics of cyclodextrin itraconazole in pediatric patients with oropharyngeal candidiasis. Antimicrob Agents Chemother 2002;46:2554–2563.
Johnson LB, Kauffman CA. Voriconazole: A new triazole antifungal agent. Clin Infect Dis 2003;36:630–637.
Koks CHW, Meenhorst PL, Bull A, Beijnen JH. Itraconazole solution: Summary of pharmacokinetic features and review of activity in the treatment of fluconazole-resistant oral candidiasis in HIV-infected persons. Pharmacol Res 2002;46:195–201.
Koltin Y, Hitchock CA. Progress in the search for new triazole antifungal agents. Curr Opin Chem Biol 1997;1:176–182.
Tacconelli E, Bertagnolio S, Posteraro B, et al. Azole susceptibility patterns and genetic relationship among oral Candida strains isolated in the era of highly active antiretroviral therapy. J Acquit Immune Defic Syndr 2002;31:38–44.
Terrell CL. Antifungal agents. Part II. The azoles. Mayo Clin Proc 1999;74:78–100.
Villanueva A, Gotuzzo E, Arathoon EG, et al. A randomized double-blind study of caspofungin versus fluconazole for the treatment of esophageal candidiasis. Am J Med 2002;113:294–299.
Worthington HV, Clarkson JE, Prevention of oral mycositis and oral candidiasis for patients with cancer treated with chemotherapy: Cochrane systematic review. J Dent Educ 2002;66:903–911.
Cheilitis Glandularis
Cheilitis glandularis is a rare chronic inflammatory disorder of the lower lip characterized by hyperplasia of the minor salivary glands.
The etiology of cheilitis glandularis is unknown.
•Lip enlargement
•Typically, the orifices of the secretory ducts become dilatated and appear as numerous pinhead openings from which mucus or mucopurulent secretion may be expressed on pressure
•Crusting, erosions, and microabscesses may occur
•Characteristically, the lesions are limited to the lower lip
The clinical diagnosis should be confirmed by a biopsy and histopathologic examination.
•Cheilitis granulomatosa
•Melkersson-Rosenthal syndrome
•Crohn disease