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1 2015 course four self-study course The Ohio State University College of Dentistry is a recognized provider for ADA CERP credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a permanent sponsor of continuing dental education. contact us phone toll free fax smsosu@osu.edu web dentistry.osu.edu/sms ABOUT this COURSE READ the MATERIALS. Read and review the course materials. COMPLETE the TEST. Answer the eight question test. A total of 6/8 questions must be answered correctly for credit. SUBMIT the ANSWER FORM ONLINE. You MUST submit your answers ONLINE at: RECORD or PRINT THE CONFIRMATION ID This unique ID is displayed upon successful submission of your answer form. ABOUT your FREE CE TWO CREDIT HOURS are issued for successful completion of this selfstudy course for the OSDB biennium totals. CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. ALLOW 2 WEEKS for processing and mailing of your certificate. The Ohio State University College of Dentistry is an American Dental Association (ADA) Continuing Education Recognized Provider (CERP). FREQUENTLY asked QUESTIONS Q: Who can earn FREE CE credits? A: EVERYONE - All dental professionals in your office may earn free CE credits. Each person must read the course materials and submit an online answer form independently. Q: What if I did not receive a confirmation ID? A: Once you have fully completed your answer form and click submit you will be directed to a page with a unique confirmation ID. Q: Where can I find my SMS number? A: Your SMS number can be found in the upper right hand corner of your monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for your office only, and is the same for everyone in the office. Q: How often are these courses available? A: FOUR TIMES PER YEAR (8 CE credits). Page 1

2 2015 course four written by ashleigh n. briody, dds edited by ross white, bs rachel a. flad, bs release date October 26, 2015 ORAL CANDIDIASIS The purpose of this course is to review the types of oral candidiasis and how they present to better help clinicians and the dental team recognize and treat all patients. In addition to reviewing the common types and presentations, this course will review the symptoms, differential diagnoses, treatment options and contraindications, and answers to a few commonly asked patient questions. Case 2 Case 1 CASE STUDIES A 67 year-old woman presented to the dentist with a 6 month history of a midline palatal ulcer. The patient reported wearing her denture 24 hours a day. The long-standing ulcer was causing the patient pain, but she still continued to wear her dentures around the clock. An evaluation of the oral mucosa revealed red patches on the palate and a somewhat rough area on the posterior portion of the denture. The patient was also taking numerous medications which contributed to dry mouth. The oral mucosa and the denture were swabbed and cultured, and showed positive for Candida albicans. The patient was treated with Clotrimazole troches and advised to soak her denture in a diluted bleach solution at night, during the antifungal treatment. After three weeks, the patient reported that the ulcer had healed and she was no longer experiencing any discomfort. A 43 year-old woman with a noncontributory medical history presented for a routine dental treatment. The dentist noticed white and red lesions on the hard palate. The patient reported that her husband told her she sleeps with her tongue pushed to the roof of her mouth. The patient also had a three week history of a cut near her left commissure, but otherwise was unaware of any lesions. The dentist consulted with an oral pathologist, and an exam revealed a red area in the central portion of the dorsal tongue, angular cheilitis, and a kissing lesion on the hard palate. The white areas were thought to be slight hyperkeratosis caused by the chronic rubbing of her palate with her tongue while sleeping. The culture was positive for Candida albicans. last day to take the course at no charge November 20, 2015 last day course is available for credit December 31, 2017 Longstanding Ulcer on the Posterior Hard Palate Dr. Ashleigh Briody, The Ohio State University College of Dentistry Multifocal Candidiasis with Central Papillary Atrophy Dr. Ashleigh Briody, The Ohio State University College of Dentistry Page 2

3 The patient was prescribed 100 mg of Fluconazole for one week, after stating she did not like the oral troches (Mycelex) and had trouble remembering to take the troches five times per day. The patient returned for routine treatment and no evidence of yeast was found. Case 3 A 70 year-old white male presented to the dental clinic with a six month history of a sensitive oral mucosa. His medical history signified that he had a liver transplant and that he had been taking antirejection drugs including corticosteroids and tacrolimus for many years. He stated that he had not been able to eat any spicy or hot-temperature foods for several months. He and his wife were very frustrated with his symptoms, since he could only eat very bland food. The additional oral examination revealed red lesions at the commissures consistent with angular cheilitis, a very smooth tongue (atrophic tongue), erythematous tissue on his palate, and alveolar mucosa consistent with denture stomatitis. Case 4 A 27 year-old black female presented to oral pathologists at the dental clinic for evaluation of oral mucosal lesions. The patient s medical history was indicative for systemic lupus erythematosus with kidney involvement and the patient was taking several immunosuppressive medications, including Prednisone, Hydroxychloraquine (Plaquenil), and Mycophenolate (CellCept). The intraoral examination revealed numerous white plaques resembling curdled milk that wiped off with gauze,while the underlying mucosa was red and tender. The patient complained of pain when eating and drinking. An exfoliative cytology was performed and the results showed candidal hyphae admixed with epithelial cells. Pseudomembranous Candidiasis in and Immunocompromised Patient Dr. Ashleigh Briody, The Ohio State University College of Dentistry Denture Stomatitis Dr. Ashleigh Briody, The Ohio State University College of Dentistry Due to the patient s severely immunocompromised status and complex medical history, the primary care physician was advised of the results and the patient was placed on preventative regimen of 100 mg of Fluconazole daily. A culture was performed, which came back positive for Candida, and the patient was placed on Clotrimazole troches (Mycelex). A systemic antifungal medication, such as Fluconazole, was determined to conflict with one of his antirejection medications: tacrolimus. The patient was also instructed to use over-the-counter Clotrimazole antifungal cream in the corners of his mouth and/or to lick the corners of his lips while dissolving the oral troche. Summary As shown in these cases, proper diagnosis and treatment of candidiasis will improve a patient s symptoms. Candidiasis can present in obvious or very subtle ways. As the dental team, recognition of the variations are very important because the oral cavity is our area of expertise. Many other medical professionals are not familiar with the different oral presentations of candidiasis, therefore patients go undertreated. This can result in delayed healing of wounds and Page 3

4 discomfort in a patient who would otherwise be cured by administration of antifungals. ORAL CANDIDIASIS OVERVIEW Oral candidiasis is a fungal infection of the top layer of the oral mucosa caused by Candida albicans. This very common dimorphic yeast exists in two forms: yeast (unicellular) and hyphal (multi-cellular). In the yeast form, the fungus is commensal with the host, but when the oral conditions change, the yeast can transform into the hyphal form, which is pathogenic. Up to 50% of patients can have yeast as part of their normal oral flora, with no signs or symptoms of disease. Numerous factors and conditions can contribute to the development of an oral candidiasis infection: immune status, oral mucosal environment, and the virulence of the Candida strain. Previously, candidiasis was thought to only occur as an opportunistic infection in patients who were inflicted with other diseases, such as those that modify immune status. Candida is commonly seen in newborns, the elderly, and those individuals who are immunocompromised. However, it can also be seen in otherwise healthy individuals. Common Causes Xerostomia is a common side effect of many medications that treat a wide range of medical conditions. These medications include, but are not limited to, those that are used to treat depression, pain, hypertension, and insomnia. Immunocompromised patients include those who are HIV-positive, post-transplant patients taking antirejection drugs, and those individuals with autoimmune diseases who take medications to suppress his or her immune system. Other patients who may be at an increased risk for developing candidiasis include those with conditions of increased keratin. Lesions that appear white in the mouth are caused by excess keratin production, and because of this, they may be subjected to increased presence of yeast due to the organism feeding on the extra keratin. Lichen planus, lichenoid mucositis, and oral leukoplakias have all been connected to increased keratin production. When Candida is present on a preexisting white lesion, the body s response to the infection can cause the lesion to appear more troublesome than normal. Disease Spectrum & Presentation The disease spectrum for candidiasis widely varies from an asymptomatic carrier state to life threatening disseminated candidiasis. The treatment for the spectrum of candidiasis also ranges from topical antifungal to very potent intravenous medications. Typically, oral candidiasis is a very superficial infection and will require minimal medication for resolution. However, in cases of the severely immunocompromised, the fungus can deeply invade the tissue and, if untreated, the disease can result in death. Oral candidiasis presents in a number of ways including pseudomembranous candidiasis, erythematous candidiasis, denture stomatitis, hyperplastic candidiasis, and angular cheilitis. The most recognizable form of candidiasis acute pseudomembranous candidiasis, also known as thrush presents as a white cottage cheese-like plaque on the buccal mucosa, palate, or dorsal tongue. These lesions wipe off with gauze or by scraping with a tongue blade, revealing an intact mucosa underneath which could look normal or red. In some patients, no symptoms are reported, while others will report a bad taste or burning sensation in the mouth. This type of candidiasis can develop acutely, after the use of broad spectrum antibiotics, or chronically, in immunocompromised patients. In patients with pseudomembranous candidiasis, diagnosis can be established with a clinical exam, exfoliative cytology, or culture. FORMS OF CANDIDIASIS Erythematous Candidiasis The most common form of candidiasis is erythematous candidiasis. This presents as red areas and can occur on the tongue, oral commissures, and the palate. Some patients report a burning sensation, while others report no symptoms. On the tongue, erythematous candidiasis often presents with a central bald patch, referred to as central papillary atrophy (formerly called median rhomboid glossitis). Page 4

5 Patients also have presented with a generalized smooth tongue which is known as acute atrophic candidiasis. The smoothness of the tongue results from the papillae undergoing atrophy as a result of the yeast feeding on the keratin that is on the dorsal surface of the tongue. A bald tongue resulting from candidiasis may be confused with a Vitamin B 12 deficiency or other blood abnormality, which will be discussed in the differential diagnosis section on Page 6. A simple culture can rule out candidiasis. Angular Cheilitis When candidiasis presents in the corners of the mouth, it is referred to as angular cheilitis. This will appear as a red area with or without cracking or crusting in the commissures. Occasionally, the redness at the corners of the mouth could be caused by a cutaneous bacterial infection, with or without Candida present. Chronic Hyperplastic Candidiasis Another form of oral candidiasis is chronic hyperplastic candidiasis, also known as candidal leukoplakia or hypertrophic candidiasis. In this presentation, the candidal colonies appear as white plaques that cannot be wiped off. They often appear worrisome, as they mimic preneoplastic leukoplakia. The most common location for this form is the anterior buccal mucosa. Less Common Forms of Candidiasis Delayed healing in traumatic or aphthous ulcers can be caused by a Candida infection. While a non-healing ulcer may be concerning for a more serious process, Candida should be ruled out and/or treated before a biopsy is performed. Other less common forms of candidiasis include perioral candidiasis, chronic mucocutaneous candidiasis, and endocrine-candidiasis syndromes. In multifocal oral candidiasis, as seen in Case 2, the patient will present with angular cheilitis or central papillary atrophy with a kissing lesion on the palate from contact of the tongue to the palate. Perioral candidiasis is a fungal infection associated with lip-licking or chronic use of lip moisturizing products. The products can seal in the fungal organisms allowing them to flourish on the surface of the skin or lips. Chronic mucocutaneous candidiasis is associated with an immunologic defect. DENTURE STOMATITIS Acute Atrophic Candidiasis with Angular Cheilitis Chronic Multifocal Candidiasis Dr. Ashleigh Briody, The Ohio State University College of Dentistry Chronic multifocal candidiasis is a type of candidiasis that includes several presentations of oral candidiasis. Patients can have white lesions that wipe off and/or multiple red lesions on the dorsal tongue, commissures, and the palate. Although the clinical signs may be evident, patients with chronic multifocal candidiasis may be completely asymptomatic. Another presentation of candidiasis is denture stomatitis, also called chronic atrophic candidiasis. This presents as red tissue on the palate underneath a denture, varying clinically from small red papules resembling petechiae to more granular and diffuse areas of erythematous change. This is caused by the denture rubbing against the oral mucosa, creating a moist, warm environment ideal for growth of this organism. In cases of denture stomatitis, typically the Candida has colonized on the denture more than the oral mucosa. A diagnosis of denture stomatitis is often rendered clinically, but a culture provides a more definitive result. In a dentate Page 5

6 patient who presents with denture stomatitis, it may be prudent to inquire if the patient is using a night guard or other device in the mouth that could harbor yeast. When culturing a patient with suspected candidiasis, a swab should be taken from the oral cavity and the denture. In order to effectively swab the denture, the sterile cotton tip must be moistened with water prior to swabbing the inside of the prosthesis. As shown in the figure below, in the bottom culture, the right side of the agar was from the swab of the palate of a patient with denture stomatitis and the left side of the agar is from the swab of the inside of the denture. Also in the figure below, the top culture is negative for Candida, while the middle culture is positive for Candida. In cases where the denture is colonized by fungal organisms, it is important to treat the denture with antifungals which will be covered in the treatment section on Page 7. Candida Cultures DIAGNOSING CANDIDIASIS Diagnosis: Dr. Ashleigh Briody, The Ohio State University College of Dentistry The culture tube is left at room temperature for hours. If positive, the agar will show creamy white colonies usually 1-3mm in diameter. If colonies of yeast are suspected intraorally, an exfoliative cytology can be performed. In this procedure, a wet tongue blade is used to gently scrape the white lesion and the cells are then transferred to a glass slide and fixed with a high alcohol content hairspray. The slide is then processed with a Periodic acid-schiff stain which highlights the cell wall of the fungi. Differential Diagnosis Some patients with oral candidiasis may complain of mucosal burning. Once Candida has been treated or ruled out, if symptoms persist in the absence of evidence of any disease process, a diagnosis of burning mouth syndrome should be considered. Burning mouth (burning tongue) syndrome is an idiopathic neuropathic condition that can affect nerves that transmit signals about pain (burning), taste (metallic, foul, sweet, etc.), or texture (mouth feels too dry, mouth feels too wet, feels like cotton). A patient with burning mouth syndrome can have one, two, or three types of nerves involved. As mentioned earlier, the symptoms of an oral yeast infection are similar with the symptoms of burning mouth syndrome. The difference is that with burning mouth syndrome, the symptoms will persist in the absence of evidence of the disease (negative culture = no areas of concern). Treatment for burning mouth syndrome is limited since most research has been open-label trial: a clinician suggests a treatment to a patient to complete and then report back on whether or not that patient found it effective. Since not very many clinical trials have been attempted in the treatment of burning mouth syndrome, the current accepted treatment is a regiment of Clonazepam 0.25mg dissolvable tablets. Caution should be used in prescribing this for patients who are already on anti-depression or anti-epileptic medications, as they may interfere. At times, the diagnosis of candidiasis can be made with just the clinical presentation. If the symptoms are present but the clinical exam is not definitive, a culture may be performed to confirm While less commonly seen, other possible the diagnosis. This is done by using a sterile diagnoses include iron deficiency anemia, cotton tip applicator to swab the patient s mouth, Plummer-Vinson Syndrome and Vitamin B 12 then transfer the swab to Sabouraud's agar. deficiency. These conditions are usually Sabouraud's agar is used for dermatophytes and investigated after candidiasis is ruled out as the other fungi and is necessary for this procedure as etiologic factor and are explained further in the the lowered ph inhibits growth of most bacteria. following sections. Page 6

7 Iron-Deficiency Anemia Iron-deficiency anemia is the most common anemic condition in the world, has a similar presentation to candidiasis, and can be caused by several factors. These factors include increased blood loss, increased demand for erythrocytes, decreased intake or absorption of dietary iron. Increased blood loss can occur from menstruation, trauma, gastrointestinal disease, malignancy, or other conditions. In children and pregnant women, there is an increased demand for erythrocytes during human growth. If the body cannot accommodate this demand, anemia could develop. Decreased intake of iron may be seen in those with poor diet or patients who have trouble obtaining sources high in iron such as edentulous patients or elderly patients requiring assistance. One possible reason for decreased absorption of iron is a condition that has gained much media attention over the last few years gluten sensitivity. In patients who report a sensitivity to gluten, digestion of foods with the plant protein gluten can result in severe chronic diarrhea. This will reduce the ability of the intestine to absorb iron, potentially resulting in iron-deficiency anemia. Plummer-Vinson Syndrome Plummer-Vinson syndrome can also be considered in the differential for erythematous candidiasis. In patients with this rare condition, iron-deficiency is present in addition to glossitis and trouble swallowing. The condition is worth mentioning due to the increased risk of those afflicted going on to develop oral or throat cancer. This will clinically mimic candidiasis in that patients will report burning of oral mucosa, atrophy of the tongue papillae, and/or angular cheilitis. Blood tests can be obtained to rule out this condition. Patients with this condition should be monitored closely for malignancy and/or referred to otolaryngology. Vitamin B 12 Deficiency (Pernicious Anemia) Vitamin B 12 deficiency, or pernicious anemia, is an uncommon anemia caused by poor absorption of B 12. It is most commonly seen in older patients of northern European ancestry, and can also be seen in vegetarians and vegans who do not obtain other sources of B 12, since the majority of B 12 comes from animal products. Without B 12, the complex needed to facilitate stomach absorption cannot bind together, resulting in further deficiency of the vitamin. Patients with pernicious anemia often report symptoms similar to other anemic conditions such as fatigue, weakness, and headache, which are often attributed to the reduced oxygen in the blood. The oral symptoms present in Vitamin B 12 deficiency include burning of the oral mucosa, which may or may not show atrophy. In comparison to the oral symptoms of candidiasis, it is clear why both of these conditions are in the differential. Blood tests to rule out anemia or a culture to rule out candidiasis can be helpful. TREATMENT The treatment for oral candidiasis is antifungal medication. Most studies suggest that a topical antifungal will work best with patient compliance; however, each treatment has advantages and disadvantages. It is important to note that oral candidiasis requires a longer course of antifungal medication than is typically necessary to treat the genital form. Dissolvable Antifungal Treatments There are two types of oral dissolvable antifungal treatment available in the United States. Mycostatin pastilles and Clotrimazole troches are both antifungal lozenges with a mild taste that patients will dissolve in the mouth, slowly, five times per day over the course of ten days. While some oral pathologists prefer this treatment option due to its success in treating candidiasis, this treatment option has some disadvantages as it requires patient compliance to use the medication a total of fifty times, and has also been reported to cause nausea and vomiting. If a patient with intraoral candidiasis also shows signs of angular cheilitis, he or she will be instructed to lick the corners of their mouth while dissolving the troche to ensure the medication reaches the commissures. Skin Creams There are two types of skin cream that can be useful in the treating of oral candidiasis. One Page 7

8 alternative is to advise a patient to purchase overthe-counter Clotrimazole antifungal cream to massage into the commissures three to four times per day. This may be the more cost effective option. The other alternative is prescription Vytone cream (Iodoquinol and hydrocortisone) that should be used three to four times per day for the optimal resolution of candidiasis. This cream dispensed in a 1oz tube has both antibacterial and antifungal properties. Some patients will report the use of lip ointment in the commissures as a relief for the symptoms; however, this should be dissuaded. The lip ointments will seal in the yeast, allowing them to proliferate more, resulting in residual or worsening clinical appearance of candidiasis. Lip products that had direct contact with the affected area prior to antifungal treatment should be discarded to prevent reinfection. Nystatin Solution Another alternative for topical antifungal treatment is a Nystatin solution. The instructions for the Nystatin are to swish two teaspoons in the mouth for at least one minute, but up to three minutes, and then expectorate. While most patients do not like the taste, or a treatment that requires such a long contact time, Nystatin can also be used to soak dentures. Due to expensive cost, usually Nystatin is reserved only for patients with metal on their denture or a partial denture. Patients with complete dentures fabricated with acrylic can treat their dentures in a solution of one tablespoon of bleach to one cup of water. It is important to explain to patients that the bleach solution should only be used for nonmetal appliances because the bleach will oxidize the metal. It also may be prudent to mention that store bought denture cleaners do not contain the ingredients to kill yeast thus are ineffective in treating candidiasis. The denture, or other oral appliance, should be treated throughout the course of the oral antifungal medication. Fluconazole A third alternative for antifungal treatment is Fluconazole (Diflucan). Fluconazole is a systemic antifungal medication that is prescribed in 100 mg tablets for oral candidiasis. The patient will take two tablets on the first day and then one tablet daily for the next 7 to 14 days. In contrast, Fluconazole for vaginal yeast infections is prescribed as a 150mg tablet to be taken only one time. Since this is a systemic medication, prescribing it to patients taking numerous other medications or altered liver status may be contraindicated. Some of the contraindication medications include: oral hypoglycemic agents, coumarin-like drugs, phenytoin (Dilantin), cyclosporine, rifampin, theophylline, rifabutin, and tacrolimus. In cases of non-resolution, Ketoconazole can be prescribed in a 200 mg tablet for one to two weeks. This medication has severe interaction with erythromycin, however, and could alter the metabolism of a number of other medications. Patients with liver dysfunction or disease should be closely monitored by a physician. Oral Suspensions Two other oral suspensions are Itraconazole (Sporanox) and Amphotericin B (Fungizone). These should not be confused with the same medications administered in other forms. Itraconazole for oral candidiasis can be administered as 10 ml (100 mg) doses. The solution is vigorously swished in the mouth and swallowed twice a day for one to two weeks. Patients with liver dysfunction or disease should be closely monitored, and this medication is contraindicated with erythromycin, oral triazolam, and oral midazolam. Amphotericin B can be administered in 1 ml (100 mg) doses. The patient should rinse and hold in the mouth for as long as possible four times daily for two weeks. Amphotericin B suspension has been reported to cause a rash and gastrointestinal symptoms but is not contraindicated with any medications in this form. Both of these oral suspensions require a fair amount of patient compliance and are not used routinely for oral candidiasis treatment. Other Treatments A new muco-adhesive patch has been developed that patients place inside their cheek. The patch releases the antifungal medication, miconazole, over a course of more than 5 hours and is reported to be well-tolerated and has good patient compliance. Studies are ongoing to determine if this method has better results than the traditional treatments for oral candidiasis. Page 8

9 COMMONLY ASKED QUESTIONS REGARDING CANDIDIASIS Is this the same as a genital yeast infection? Candida can occur in the oral cavity, on the skin, gastrointestinal mucosa, vulvovaginal and penile areas, as the ideal environment for Candida species to grow is a warm moist area. Over 90% of genital yeast infections are caused by Candida albicans, the same fungus responsible for oral candidiasis. Similar to the oral cavity, an infection occurs when an imbalance in the normal healthy flora (microorganisms) occurs, whether it be due to medication, ph change, or hormones, the yeast can multiply. The yeast then will feed on the surface layer of the mucosa contributing to the symptoms. The symptoms range from burning or itching to cottage cheese-like plaques or discharge. Genital yeast infections can occur in men and women, and the symptoms can be similar to other genital infections. Is candidiasis contagious? While candidiasis is not considered contagious, in the right setting it can be passed from person to person. In a person with a healthy immune system, the opportunistic yeast would not establish in the oral or genital area. However, if a susceptible individual, such as an immunocompromised patient, was exposed to the fungus, the patient could develop candidiasis as a result. Most often, Candida does not spread from person to person. point rendering the organism incapable of pathogenicity, thus bread and other yeast containing products do not need to be avoided. Ultimately, both yeast types are treated in a similar manner. Why did I get a yeast infection in my mouth? Several factors can contribute to developing oral candidiasis. It can occur in patients who are stressed, taking antibiotics, taking medications that cause dry mouth, or who have a hormone imbalance. Sometimes, the actual cause of the candidiasis may be hard to pinpoint. In patients with chronic dry mouth, drinking water throughout the day to keep the oral mucosa hydrated can be beneficial in preventing a ph change that would allow for the yeast to outgrow the normal oral bacteria. CONCLUSION There are many forms of oral candidiasis. Some present in very classic ways and others are much more subtle. The use of cytologic smears and cultures can aid in the diagnosis. While oral candidiasis is caused by the same organism as other forms, it requires a longer course of antifungals. It is crucial for the dental team to explore all possible diagnoses to aid in the treatment of the patient. References available upon request. Are there any foods I should avoid? Many patients hear the words yeast infection and inquire about a relationship with bread or other foods that contain yeast. The yeast in bread, wine, and beer Saccharomyces cerevisiae is a different genus and species than the pathogen responsible for most oral candidiasis infections. While over 90% of candidiasis is attributed to Candida albicans, and the majority of the rest attributed to other species in the genus Candida, a very small percentage (less than 1%) has been attributed to S. cerevisiae. In this very small percentage, it is important to note that the researchers could not prove that S. cerevisiae was the sole organism. In bread, wine, and beer, the yeast is processed to a ABOUT THE AUTHOR ASHLEIGH N. BRIODY, DDS ASHLEIGH BRIODY GRADUATED FROM LOUISIANA STATE UNIVERSITY SCHOOL OF DENTISTRY IN NEW ORLEANS, LOUISIANA. SHE IS CURRENTLY A SECOND YEAR RESIDENT IN THE ORAL AND MAXILLOFACIAL PATHOLOGY PROGRAM AT THE OHIO STATE UNIVERSITY COLLEGE OF DENTISTRY. HER FUTURE CAREER PLANS INCLUDE SUPPORTING A BIOPSY SERVICE AS WELL AS TREATING AND MANAGING PATIENTS WITH ORAL DISEASE. DR. BRIODY CAN BE REACHED AT BRIODY.2@OSU.EDU Page 9

10 post-test instructions - answer each question ONLINE - press submit - record your confirmation id - deadline is November 20, 2015 The difference between oral candidiasis and burning mouth syndrome is that burning mouth syndrome symptoms persist in the absence of evidence of the disease. 1 T F SUBMIT 2 T F Oral suspensions are the ideal treatment for oral candidiasis due to the ease of patient compliance. 3 ONLINE T F 4 T F Oral candidiasis and vaginal candidiasis are treated with the same duration of antifungals. The yeast organism can thrive in the oral cavity by feeding on the extra keratin that is present. SUBMIT 5 T F 6 T F Most often, Candida does not spread from person to person. ONLINE 7 T F 8 T F The yeast form of candida is pathogenic and the hyphal form is commensal. Candidal leukoplakia is most common in the anterior buccal mucosa and can be wiped off. Iron-deficiency anemia has been linked to gluten sensitivity. d i r e c t o r john r. kalmar, dmd, phd kalmar.7@osu.edu program manager ross white, bs white.1483@osu.edu channel coordinator rachel a. flad, bs flad.4@osu.edu senior laboratory preparator katherine j. myers myers.1235@osu.edu Page 10