© Springer-Verlag Berlin Heidelberg 2015
Edvaldo Antonio Ribeiro Rosa (ed.)Oral Candidosis10.1007/978-3-662-47194-4_7
7. Candida-Associated Denture Stomatitis: Clinical Relevant Aspects
Andréa Araújo de Vasconcellos1, Letícia Machado Gonçalves2, Altair A. Del Bel Cury3 and Wander José da Silva3
Faculty of Dentistry, Federal University of Ceará, Sobral, Ceará, Brazil
Faculty of Dentistry, CEUMA University, São Luiz do Maranhão, Maranhão, Brazil
Department of Prosthodontics and Periodontology, Piracicaba Dental School, State University of Campinas, Piracicaba, SP, Brazil
Wander José da Silva
Candida-associated denture stomatitis is a common fungal infection that affects removable denture wearers. Although Candida spp. are considered commensal fungal in the oral cavity, changes in local and/or systemic predisposing factors related to the host conditions may lead to pathogenic form and cause disease. The clinical manifestations are usually associated with the predisposing factors, changing from no symptoms to severe pain and difficulty swallowing. The therapeutic strategies commonly adopted in the clinical practice are the use of topical and/or systemic antifungal, in addition to removing mechanically the plaque from denture surfaces and from underlying mucosa and give instructions about the correct oral hygiene to the patient. In this context, considering the high prevalence of this disease in the clinical practice, a review about the etiology, risk factors, clinical manifestations, and therapy management of these patients is of utmost importance.
Candida Risk factorsDenture stomatitisTherapeutics
Candida-associated denture stomatitis is a predominantly fungal infection that affects the human oral cavity (Harriott and Noverr 2011). Although Candida spp. may be involved during infection, Candida albicans are considered the main pathogens, and have been found in a commensalism form in the oral cavities of adults and children, without any clinical disease (Lalla et al., 2013). These microorganisms are encountered in the dentition, tongue, cheeks, palatal mucosa, restorative materials, and oral prostheses (Sánchez-Vargas et al., 2013).
However, local and/or systemic predisposition factors may lead commensal microorganisms to pathogenic form, providing an oral environment adequate to the adhesion of microorganisms to the denture surface and mucosal epithelial cells (Sardi et al., 2013). This is followed by cell multiplication, organization, and secretion of extracellular matrix, resulting in the formation of biofilm, an highly organized three-dimensional structure (Jayatilake 2011).
Also, C. albicans may be found in two major forms, yeast and hyphae form. The yeast form is usually associated with mucosal commensalism, although the conversion yeast-to-hyphae is commonly related to the invasion of superficial layers of the oral epithelium, leading to clinical infection (Vallejo et al., 2013).
Although Candida albicans have been the main pathogens of CADS, C. glabrata, C. Tropicalis, and C. parapsilosis has been found less frequently (Vazquez and Sobel 2002; Dorocka-Bobkowska and Konopka 2007). Some factors favor the development of C. albicans biofilms, such as its capability to stick and proliferate through the denture surfaces and oral mucosal epithelial and produce a complex and heterogeneous bacterial biofilm (Salerno et al., 2011).
CADS has been found in 60–65 % of the denture wearers with more diffused clinical manifestations, but considering the patients that do not manifest clinical signs of inflammation and infection, this percentage increases to 75 % (Salerno et al., 2011; Webb et al., 1998a). It was reported that CADS is the most common oral mucosal lesion associated with removable dentures (Cueto et al., 2013), and affects one in every three complete denture wearers (Zissis et al., 2006).
The changes from commensal to pathogenic form of Candida spp. are typically caused by local and/or systemic predisposing factors related to the host conditions, favoring the development of the disease. While the local factors provide an adequate oral environment to biofilm development, the systemic factors influence the defense host mechanisms (Lalla et al., 2013; Salerno et al., 2011).
The local factors are important to favor the biofilm accumulation in the oral environment. In this context, different factors such as irradiation, trauma, xerostomy, complete denture wearers, poor dental hygiene, smoke, carbohydrate-rich diet, and environmental pH will be discussed.
The irradiation is considered a risk factor, considering that it leads to hiposalivation (Nett et al., 2010). Also, xerostomy is another condition that reflects the decrease or the complete absence of saliva (Webb et al., 1998b), reducing the ability of cleaning and buffering of saliva. Furthermore, previous study showed that patients with xerostomy induce changes that reflect in the normal microbial communities, favoring the proliferation of bacteria as Staphylococcus aureus, which inhibits the normal adaptation of the commensal fungals (Webb et al., 1998a).
Cigarette smoke may favor CADS, considering the changes that cause in the oral cavity, influencing on saliva, oral commensal bacteria and fungi, especially Candida, the main fungal related to CADS (Soysa and Ellepola 2005). Another important factor is the trauma. Although trauma alone does not induce to generalize CADS, it should be considered that trauma acts as a cofactor, favoring the adhesion and penetration of the yeasts in the oral epithelium mucosa of the host (Emami et al., 2008). Denture trauma due to poorly adapted denture is an important cofactor of CADS.
Complete denture wearers are also a risk factor, considering that Candida spp. are frequently found on oral mucosa and on denture surfaces (Sánchez-Vargas et al., 2013; Daniluk et al., 2006). In addition, it was observed that the presence of C. albicans in the oral cavity in patients with dentures was higher than in patients who do not use dentures (Daniluk et al., 2006). Furthermore, poor oral hygiene favors the biofilm development (Daniluk et al., 2006), and therefore it is important to have a correct oral hygiene.
A carbohydrate-rich diet also favors the microorganisms adhesion and proliferation, taking into account that the carbohydrates are the primary and preferred nutrient source for Candida spp. (Emami et al., 2014), and may modulate biofilm development on denture surface by affecting both structural features and virulence factor in C. albicans biofilms (Ene et al., 2012).
There are a lot of systemic conditions that may influence the development of CADS. Here, diabetes, chemotherapy, hemophilia, and immunosuppressed patients will be emphasized.
Diabetes mellitus is one of the chronic systemic factors with major influence of the oral environment (Vasconcellos et al. 2014). Considering the lower glycemic control, the high glucose level on oral fluid, and the immune dysregulation, diabetes frequently causes xerostomy, which favors fungal proliferation (Girtan et al., 2009).
Furthermore, patients undergoing chemotherapy are particularly affected by CADS, due to high sensibility of the oral tissues to the toxic effects of chemotherapy. Antineoplastic drugs act on proliferating cells without distinguishing the normal cells from cancerous cells. In this context, the constant cell renewal of the oral mucosa, the complex microbiota (greatly altered with the use of anticancer drugs), xerostomy, neutropenia, and immunosuppression resulted from the treatment facilitated proliferation of Candida