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Oral Health: The case of the burning tongue Topic: Oral Health Date Posted: Wednesday, May 29, 2002 |
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Case Solution:
The Correct Answer is: c. Erythematous candidiasis.
What is erythematous candidiasis? Erythematous candidiasis is a red, flat, subtle lesion that may appear anywhere in the oral cavity but the majority of time presents on the dorsal surface of the tongue and/or the hard and soft palates. This lesion is one of the most under diagnosed oral diseases seen in people living with HIV- infection. One paper authored by Hilton et al, entitled, ýAccuracy of diagnoses of HIV-related oral lesions by medical clinicians. Findings from the Women's Interagency HIV Studyý (Community Dent Oral Epidemiol 2001 Oct;29(5):362-72) found that medical clinicians recognize that HIV-related oral abnormalities are present in 40-75% of cases, but less often describe them accurately. In this study only 58% of the medical providers were able to accurately recognize erythematous candidiasis. Erythematous candidiasis can be symptomatic with the chief complaint being burning, usually associated with eating salty or spicy foods. Diagnosis of erythematous candidiasis is based upon clinical appearance, taking into consideration the patientýs underlying medical history, but the presence of hyphae and blastospores, seen on KOH smears, can help confirm the diagnosis. This lesion resembles pizza burn and/or traumatic lesions of the hard and soft palate, but these two presentations are normally self-limiting and do not require therapy. How often do we see erythematous candidiasis? Erythematous candidiasis was found to be the most common oral manifestation in a large cross-sectional study published in December 2001 entitled "The effect of antiretroviral therapy on the prevalence of oral manifestations in HIV-infected patients: A UK study" (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:623-8). Whereas most studies so not differentiate between the prevalence of erythematous candidiasis and pseudomembranous candidiasis there are reports of prevalence ranging from 6.9% (Tsang PC, Samaranayake LP. Oral manifestations of HIV infection in a group of predominantly ethnic Chinese. J Oral Pathol Med 1999 Mar;28(3):122-7) to 21% for those included in the UK study who were not on HAART. How is erythematous candidiasis treated? Erythematous candidiasis, as previously mentioned, normally presents on the dorsal surface of the tongue and/or the roof of the mouth. Due to the limited nature of this fungal infection, treatment normally requires topical antifungal therapy. As HIV disease progresses and immunosuppression becomes more severe, the incidence and severity of oropharyngeal candidiasis increase. The introduction of oral azoles, most notably fluconazole, has led to the increased incidence of azole resistant Candida albicans as well as the emergence of non-albicans species such as Candida glabrata, which are inherently resistant to this class of drug. (Powderly WG, Mayer KH, Perfect JR. Diagnosis and treatment of oropharyngeal candidiasis in patients infected with HIV: a critical reassessment. AIDS Res Hum Retroviruses 1999 Nov 1;15(16):1405-12) Factors, which increase the probability of presenting azole resistant strains of Candida in the oral cavity, include previous exposure to azoles, low CD4 count and the presence of non-albicans species.( Maenza JR, Keruly JC, Moore RD, Chaisson RE, Merz WG, Gallant JE. Risk factors for fluconazole-resistant candidiasis in human immunodeficiency virus-infected patients.J Infect Dis 1996 Jan;173(1):219-25) (Cartledge JD, Midgley J, Gazzard BG. Non-albicans oral candidosis in HIV-positive patients. J Antimicrob Chemother 1999 Mar;43(3):419-22). To minimize the risk of resistance, topical therapies should be considered for first-line treatment of initial or recurrent cases of mild to moderate oropharyngeal candidiasis. Systemic therapies should be utilized for moderate to severe cases. (Powderly WG, Mayer KH, Perfect JR Diagnosis and treatment of oropharyngeal candidiasis in patients infected with HIV: a critical reassessment. AIDS Res Hum Retroviruses 1999 Nov 1;15(16):1405-12) Featured Provider Materials: https://aids-ed.org/educational/provider/topics/pro_oral.jsp Also see the HRSA Care Action Newsletter: http://hab.hrsa.gov/publications/april2002.htm > Case Detail |
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