Causes and prevention of oral candidiasis in South Indian population

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1 Research Article Causes and prevention of oral candidiasis in South Indian population Prabhav Kumar Iyer 1, R. Gayatri Devi 2 *, A. Jyothipriya 2 ABSTRACT Introduction: Oral candidiasis is one of the most oral fungal infections. It is caused by the members of the Candida species. It is marked by the appearance of numerous white patches in the oral cavity, especially on the tongue and the buccal mucosa. This infection is caused mainly by Candida albicans, which is a part of the normal microflora of the oral cavity. Its growth increases due to poor oral hygiene especially in people with dentures (either removable or fixed). Hence, this study focuses on the causes and the prevention parameters of oral candidiasis rather than its treatment. Materials and Methods: A total of 40 people aging from 50 to 90 years old denture wearers who have or had oral candidiasis in their past were studied. Their denture cleaning habits, their diet, their smoking habits, and their drug intake (if any) were recorded. A tabular column was created and their responses were recorded. Results: It was found that candida growth was more in years patients, with a rich carbohydrate diet, asthmatics, who did not religiously clean their dentures. No concrete proof was found to relate smoking and growth of candida. Conclusion: Oral candidiasis is a fungal infection which affects older denture patients who had a rich carbohydrate diet, who were asthmatics, and who did not maintain proper oral hygiene. A relationship between smoking and candida growth could not be established. KEY WORDS: Candida, Carbohydrate, Denture, HIV, Smoking INTRODUCTION Candida is prevalently found in the oral cavity as a member of the normal microflora in the oral cavity. The members of Candida species appear as large, round, and white colonies which emit a yeasty odor on agar plates at room temperature. It is also one of the most common opportunistic infections in AIDS. Candida is grouped under three consisting of acute candidiasis, chronic candidiasis, and angular cheilitis. Risk factors include impaired salivary gland function, drugs, dentures, high carbohydrate diet, and extremes of life, smoking, diabetes mellitus, Cushing s syndrome, malignancies, and immunosuppressive conditions. [1] Fortunately, the vast majority of the cases of oral candidiasis is not life threatening and readily respond Access this article online Website: jprsolutions.info ISSN: to appropriately administered anticandidal agents. It must always be remembered, however, that the organism has the capacity to produce fulminating fatal infection by hematogenous dissemination from seemingly innocuous oral infections that serve as a portal of entry to the systemic circulation. [2] A variety of nutritional factors including deficiencies of iron, folic acid, vitamins, and diets rich in carbohydrates have been implicated in the pathogenesis of oral candidal infections. Even though much controversy exists as to the specific roles played by these individual factors, there is little doubt that nutritional factors could significantly affect the pathogenesis of oral candidiasis. [3] Since candidiasis is the most common opportunistic infection in HIV positive patients, a cure for it should be administered as soon as possible. There are various methods for the treatment of oral candidiasis. A study done by Barasc et al. suggests that the topical disinfectant Chlorhexidine may be a promising agent for treating and preventing oral 1 Department of Physiology, Saveetha Dental College, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, Tamil Nadu, India, 2 Department of Physiology, Saveetha Dental College, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: R. Gayatri Devi, Department of Physiology, Saveetha Dental College, Saveetha Institute of Technical and Medical Science, Saveetha University, 162, Poonamallee High Road, Chennai , Tamil Nadu, India. Phone: gayatri.physio88@gmail.com Received on: ; Revised on: ; Accepted on:

2 candidiasis in HIV-infected children. [4] Another study done by Garcia-Cuesta et al. showed that Fluconazole is the preferred choice for oral candidiasis. [5] The body also as a mechanism to deal with candida overgrowth. Antimicrobial proteins in the saliva such as lactoferrin, sialoperoxidase, lysozyme, histidinerich polypeptides, and specific anti-candida antibodies interact with the oral mucosa and prevent overgrowth of candida. [6] This study focuses on the causes and the prevention parameters of oral candidiasis rather than its treatment. MATERIALS AND METHODS A total of 40 people ranging from the age of 50 to 90 years who wore dentures and who have oral candidiasis or had the infection earlier in their life were taken in this study. A list was prepared on their habits regarding maintaining oral hygiene, their diet and any other drug consumption that might have factored toward the overgrowth of candida. RESULTS The study consisted of 22 males and 18 females. All of the above people wore dentures and had oral candidiasis currently or had it sometime in the past. Results were discussed below. Out of the 40 people, 17% were between 50 and 60 years of age, 30% were between 61 and 70 years of age, 25% were between 71 and 80 years of age, and the rest 28% were between 81 and 90 years of age [Figure 1]. 42% of people in the age group of years showed low growth, 33% showed medium growth, and 25% showed high growth [Figure 2]. 77% of the people had a majority of carbohydrate diet while the 23% said they had a majority of proteinrich diet [Figure 3]. 32% of people in the age group of years showed low growth, 39% showed medium growth, and 29% showed high fungal growth [Figure 4]. This was done to assess whether or not the presence of glucose in the oral cavity enhanced the growth of Candida in their oral cavity. The number of washes given to dentures every day was a major staple in determining the hygiene of the oral cavity. 30% of the people said that they clean their denture at least once daily, 22% of the people said they clean their dentures twice daily, 15% said that they clean it thrice a day, 8% said that they clean their dentures 4 times a day, and 3% said that they clean it 6 times a day [Figure 5]. Surprisingly, 22% said that they do not clean their dentures on a daily basis as they believed that drinking water regularly would clean Figure 3: Diet Figure 1: Age Figure 2: Fungal growth with age Figure 4: Fungal growth in diet 982

3 the dentures. When the fungal growth of people with a rich carbohydrate was checked, it was found that 29% had high fungal growth, 39% had medium fungal growth, and the remaining 32% had low fungal growth. In cases where dentures were uncleaned, high fungal growth was seen in 67% of the cases [Figure 6]. In cases, where the dentures were cleaned once daily, high fungal and growth was seen only in 8% of the cases. In cases, where dentures were cleaned twice daily, and high fungal growth was seen in 22% cases. In cases, where dentures were cleaned thrice daily, and high fungal growth was seen in 33% cases. In cases, where dentures were cleaned 4 times daily, and high fungal growth was seen in 33% cases. Moreover, in cases, where dentures were cleaned 6 times daily, and low fungal growth was seen in all cases. Some of the patients were asthmatic, so the steroidal component of their nasal inhalers was recorded. 15% of the total used Fluticasone, 2% used Beclamethosone, and 3% used Budesonide [Figure 7]. It was also seen that 62% of the people who were asthmatic had high fungal growth, 25% had medium growth, and 13% had low growth [Figure 8]. To check whether smoking increased Candida growth in the oral cavity, smoking population was checked. It was found that 30% were smokers and 70% were non-smokers [Figure 9]. In the 30% population of smokers, 67% had low fungal growth while 33% had high fungal growth [Figure 10]. A study done by Akpan and Morgan showed that the growth of candida in saliva is enhanced by the presence of glucose and its adherence to oral epithelial cells is enhanced by a high carbohydrate diet.[6,7] Similarly, a study done by Singh et al. showed that drugs such as inhaled steroids have been shown to increase the risk of oral candidiasis by possibly suppressing cellular immunity and phagocytosis.[6] DISCUSSION Candida species present both as normal commensals and opportunistic pathogens of the oral cavity in case of HIV infections. For decades, it has excited the clinicians to investigate its pathogenicity and to improvise newer therapeutic remedies based on the updated research.[7] 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.[8] This study found that in the age group of years, 42% had low bacterial growth. A study done by Figure 5: Times denture cleaning Figure 7: Drugs taken Figure 6: Fungal growth in uncleaned denture Figure 8: Fungal growth in drugs 983

4 Figure 9: Smoker that there was smoking has an influence on oral colonization with Candida species. [13] Since Candida forms a part of the normal microflora of the mouth, it s overgrowth can be prevented by simply keeping the dentures clean. This can be done by regularly washing the denture with clean water and by brushing it with toothpaste. Some researchers found out that there was a positive corelation between blood glucose level and oral candidiasis. This is caused by increased adherence of Candida albicans to diabetic compared to nondiabetic cells. [14] Some researches even showed that the intake of corticosteroids in the form of nasal sprays for asthmatic patients has immunosuppressive actions which enhance candidal growth. This study offers the further scope of research for a larger population of patients, and a better prevention method could be introduced. CONCLUSION Figure 10: Fungal growth in smokers Loster et al. showed that intermediate, intensive, and abundant growth were seen in people between the age of 60 and 70. [9] This study found that only 29% of people with carbohydrate-rich diet showed high fungal growth. A study done by Ganapathy et al. showed that there is a positive correlation between oral candidiasis in denture-bearing mucosa and elevated blood glucose levels in complete denture wearers with Type II Diabetes Mellitus. [10] When dentures were cleaned more times per day, the fungal growth was less. A study done by Kanli et al. showed that only 16.7% of dentures worn by the elderly are properly cleaned. Older dentures tended to be dirtier than newer ones. There was a significant correlation between poor denture hygiene and prevalence of Candida. [11] This study showed that 62% of asthmatics had high fungal growth. A similar study done by Fukushima et al. showed that the amount of Candida spp. was significantly greater in asthmatic patients taking inhaled steroids compared with those who were not. [12] This study found that out of the 30% people who smoked, only 33% showed signs of high Candidal growth. A study done by Muzurović et al. showed This study concluded that: Candida occurs in the group of years old patients greater than any other of patients taken in the study. People in taking a carbohydrate-rich diet are more prone to oral candidiasis. There is an indirect correlation of times a denture cleaned daily and the growth of Candida species. Intake of corticosteroids has an immunosuppressive activity which enhances candidal growth. There was not enough evidence to prove a relationship between smoking and the growth of candida. REFERENCES 1. Akpan A, Morgan R. Oral candidiasis. Postgrad Med J 2002;78: Dreizen S. Oral candidiasis. Am J Med 1984;779: Samaranayake LP. Nutritional factors and oral candidiasis. J Oral Pathol 1986;15: Barasch A, Safford MM, Dapkute-Marcus I. Effects of chlorhexidine gluconate rinse for treatment and prevention of oral candidiasis in HIV-infected children: A pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112: Garcia-Cuesta C, Sarrion-Pérez MG, Bagán JV. Current treatment of oral candidiasis: A literature review. J Clin Exp Dent 2014;6:e Singh A, Verma R, Murari A, Agrawal A. Oral candidiasis: An overview. J Oral Maxillofac Pathol 2014;18 Suppl 1:S Patil S, Rao RS, Majumdar B, Anil S. Clinical appearance of oral candida infection and therapeutic strategies. Front Microbiol 2015;6: Farah CS, Lynch N, Mccullough MJ. Oral fungal infections: An update for the general practitioner. Aust Dent J 2010;55 Suppl 1: Loster JE, Wieczorek A, Loster BW. Correlation between age and gender in Candida species infections of complete denture wearers: A retrospective analysis. Clin Interv Aging 2016;11: Ganapathy DM, Joseph S, Ariga P, Selvaraj A. Evaluation of the influence of blood glucose level on oral candidal colonization in complete denture wearers with Type-II diabetes mellitus: An in vivo study. Dent Res J (Isfahan) 2013;10:

5 11. Kanli A, Demirel F, Sezgin Y. Oral candidosis, denture cleanliness and hygiene habits in an elderly population. Aging Clin Exp Res 2005;17: Fukushima C, Matsuse H, Tomari S, Obase Y, Miyazaki Y, Shimoda T, et al. Oral candidiasis associated with inhaled corticosteroid use: Comparison of fluticasone and beclomethasone. Ann Allergy Asthma Immunol 2003;90: Muzurović S, Hukić M, Babajić E, Smajić R. The relationship between cigarette smoking and oral colonization with Candida species in healthy adult subjects. Med Glas (Zenica) 2013;10: Samaranayake LP, MacFarlane TW. The effect of dietary carbohydrates on the in-vitro adhesion of Candida albicans to epithelial cells. J Med Microbiol 1982;15: Source of support: Nil; Conflict of interest: None Declared 985

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