Oral candidiasis in patients receiving radiation therapy for head and neck cancer

Prospective Cohort Study Identifies Medical Predictors of Treatment-Related Oral Toxicities in Oral and Oropharyngeal Cancer Patients

The dental treatment of patients with oral cavity and oropharyngeal squamous cell carcinoma (OOPSCC) may be challenging for dentists. This study aimed to characterize systemic changes in patients with OOPSCC undergoing dental treatment prior to cancer therapy, with a specific focus on laboratory assessments. The primary objectives included identifying potential adverse events, such as infections or bleeding, resulting from dental procedures. Additionally, the study aimed to correlate baseline patient characteristics with treatment-related toxicities. This was a prospective cohort study that included 110 OOPSCC patients referred to the Dental Oncology Service at São Paulo State Cancer Institute, Brazil, between November/2019 and December/2020. Comorbidities, sociodemographic data, medication in use, cancer treatment-related toxicities, and altered laboratory tests results were correlated. The most common comorbidities and altered laboratory results were hypertension, dyslipidemia, diabetes, as well as elevated levels of C-reactive protein, hemoglobin, and hematocrit. Toxicities exhibited a progressive pattern over time, encompassing oral mucositis (OM), xerostomia, dysphagia, dysgeusia, trismus, and radiodermatitis. No correlation between comorbidities and cancer treatment-related toxicities, a positive correlation between medications in use and OM, and a negative correlation between medications and dysgeusia were found. OM was associated with altered thyroxine (T4) and free thyroxine (FT4), calcium, urea, creatinine, alkaline phosphatase, and syphilis. Family income and housing were OM predictors. Altered T4/FT4/urea/calcium/alkaline phosphatase/creatinine/syphilis may be useful clinical predictors of OM. Despite the elevated prevalence of comorbidities and abnormal laboratory findings, dental treatment prior to cancer treatment yielded no adverse events.

The influence of radiation-induced bystander effect in osteoblasts mediated by plasma-derived extracellular vesicles (EVs)

OBJECTIVES

Head and neck tumor patients may develop post-radiotherapy diseases after radiotherapy treatment. And radiotherapy can elicit radiation-induced bystander effect, wherein extracellular vesicles (EVs) play a crucial role. For normal parts of the body that have not been directly irradiated, the effect of EVs on them needs to be further explored. This study aims to investigate the functions of plasma-derived EVs in regulating normal osteoblasts during radiation-induced bystander effects.

METHODS AND MATERIALS

Rat plasma-derived EVs were isolated and identified firstly, followed by an evaluation of their intracellular biological effects on normal osteoblasts in vitro. Transcriptome sequencing analysis and confirmations were performed to identify potential mechanisms.

RESULTS

Irradiated plasma-derived EVs were found to enhance osteoblast proliferation, migration, and cell cycle progression, concurrently suppressing the expression of osteogenesis-related genes and proteins. Furthermore, these EVs attenuated the expression of osteogenesis and oxidative stress resistance related genes, while upregulating the PI3K-AKT pathway and intracellular reactive oxygen species in osteoblasts.

CONCLUSIONS

Irradiated plasma-derived EVs could alter the biological effects in osteoblasts, which is closely associated with the levels of GPX1 and the PI3K-AKT signaling pathway. This suggests that plasma-derived EVs serve as a crucial factor contributing to radiation-induced bystander effect in osteoblasts.

Microbial Analysis of Obturators During Maxillofacial Prosthodontic Treatment Over an 8-Year Period

The aim of the study was to investigate the microbial colonization (by Candida species, anaerobic and facultative anaerobic bacteria) of maxillary obturators used for the restoration of maxillary defects, including during radiotherapy.

Retrospective cohort study.

Fifteen patients requiring a maxillary obturator prosthesis had swabs of their obturators and adjacent tissues taken at different stages of their treatment over a period of 8 years.

Identification of microbial species from the swabs was carried out using randomly amplified polymorphic DNA polymerase chain reaction (RAPD PCR) analysis, checkerboard DNA-DNA hybridization, CHROMagar Candida chromogenic agar, and DNA sequencing.

Candida species were detected in all patients and all patients developed mucositis and candidiasis during radiotherapy which was associated with an increase in colonization of surfaces with Candida spp., particularly C albicans. Microbial colonization increased during radiotherapy and as an obturator aged, and decreased following a reline, delivery of a new prosthesis, or antifungal treatment during radiotherapy.

Microbial colonization of maxillary obturators was related to the stage of treatment, age of the obturator material, radiotherapy and antifungal medications, and antifungal treatment may be recommended if C albicans colonization of palatal tissues is greater than 105 colony-forming units per cm2 following the first week of radiotherapy.

Oral Health Factors Related to Rapid Oral Health Deterioration among Older Adults: A Narrative Review

Older adults who face systemic health issues and lack adequate social support are at risk for oral health deterioration. How rapidly such changes take place depends on the severity of their medical condition and their ability to access oral health services in a timely manner. The management of dental caries and periodontal disease in this cohort is made complex by the interaction of local and host factors such as the presence of dry mouth, involvement of root surfaces, and altered wound healing. in addition to enhanced maintenance needs to avoid recurrence or progression. Tooth replacement can be beneficial in restoring oral function, allowing patients to enjoy a healthy and nutritious diet but requires careful consideration to avoid further damage to remaining dental units. Establishing a dental home for the older adult can facilitate routine surveillance, disease prevention, and patient/caregiver education to achieve oral health goals commensurate with overall health. This narrative review details oral health factors that are related to rapid oral health deterioration among older adults.

Xerostomia and hyposalivation in association with oral candidiasis: a systematic review and meta-analysis

Introduction Several studies reported that hyposalivation was associated with a higher prevalence of oral Candida colonisation and oral candidiasis, and despite the correlation between these conditions, no previous systematic review was conducted to examine this relationship in its utmost depth.Objectives This study aims to investigate the relationship between xerostomia, hyposalivation and oral candidiasis.Search methods This systematic review and meta-analysis was conducted in February 2021 through an electronic search.Data sources The electronic search was performed on PubMed, Scopus, Web of Science through Clarivate, Medline through Clarivate and Cochrane Library.Data selection This systematic review and meta-analysis included cohort, observational nested case-control cohort studies, and studies of other designs providing the number of patients with and without xerostomia or hyposalivation crossed with the number of patients with and without oral candidiasis or oral Candida growth. Studies included were conducted on adult populations with no restriction to sex or race. Included studies should use a reliable diagnostic method for all conditions of interest.Data extraction Results were obtained from the implementation of the search strategy and managed using the EndNote Web and Rayyan Qatar Computing Research Institute (QCRI). Quantitative data synthesis was performed using the Review Manager 5.4 software.Results A total of 429 studies were identified by searching the databases, of which nine studies were included for qualitative and quantitative data synthesis. The analysis included 590 xerostomic patients and 697 controls subgrouped into two categories: Candida growth (207 patients and 195 controls) and oral candidiasis (383 patients and 502 controls). The Candida growth subgroup analysis shows that the xerostomic patients are at higher risk for oral Candida growth than controls (OR [95% CI] = 3.13 [2.02-4.86]) and the oral candidiasis subgroup analysis yields that xerostomic patients are at higher risk for developing manifest oral candidiasis than controls (OR [95% CI] = 2.48 [1.83-3.37]).Conclusion Our study concludes that patients with xerostomia have a higher risk than non-xerostomic control groups of developing oral candidiasis and oral fungal growth. Major inter-study heterogeneity, however, may restrict confidence in the accuracy of our results, and caution should therefore be taken in interpreting the evidence. In caring for patients with hyposalivation, we recommend healthcare professionals consider the possible association between both conditions. Furthermore, we recommend further research with improved methodological qualities and more valid diagnostic methods.

Neutrophil-to-Lymphocyte Ratio as a Factor Predicting Radiotherapy Induced Oral Mucositis in Head Neck Cancer Patients Treated with Radiotherapy

BACKGROUND

The objective of this research conducted in head and neck cancer (HNC) patients was the assessment of the relationship between neutrophil-to-lymphocyte ratio (NLR) and the incidence of severe radiotherapy (RT) induced oral mucositis (OM), as well as overall survival (OS).

METHODS

The study involved 207 patients in advanced stages (III-IV) of HNC. RTOG/EORTC scale was used to assess OM. The pre-treatment NLR was specified as the absolute neutrophil count divided by the absolute lymphocyte count.

RESULTS

Starting from second to seventh week of RT, we observed a significant, positive correlation between NLR values and OM grade. From the second to seventh week of RT, higher NLR values were related with significant increases (from 2- to over 24-fold) in the risk of occurrence of more severe OM (multivariate analysis confirmed its independent influence). Moreover, multivariate analysis for survival revealed that both higher TNM stage (HR = 1.84; p = 0.0043) and higher NLR values (HR = 1.48; p = 0.0395) were independent prognostic factors.

CONCLUSION

NLR is a simple and accurate parameter that is useful in the evaluation of the risk of more severe OM, as well as an independent prognostic factor of OS in patients subjected to RT due to HNC.

Effects of a miconazole oral patch on preventing development of oral candidiasis in patients with head and neck cancer undergoing radiotherapy: results of a preliminary study quantifying the prevalence of Candida albicans in saliva

PURPOSE

Serious oral mucositis develops during radiation therapy (RT) for head and neck cancer, but there is no effective preventive method. We have used a steroid ointment to prevent oral mucositis during RT, but the use of steroid ointment is discontinued when oral candidiasis develops. Therefore, prevention of oral candidiasis is important. The purpose of this study was to examine whether administration of a miconazole oral patch reduced the amount of Candida albicans in saliva and prevented the development of oral candidiasis during RT.

METHODS

Participants were patients with head and neck cancer receiving RT ≥ 60 Gy. Patients in the intervention group received miconazole oral patches for 14 days after the appearance of grade 2 oral mucositis. The control group received oral care only. Total bacteria and C. albicans counts in the saliva were analyzed by real-time polymerase chain reaction. The incidence of oral candidiasis was compared between the groups.

RESULTS

Total bacterial counts did not change throughout RT in either the intervention or the control group. However, C. albicans count significantly increased at 30 Gy and 60 Gy in the control group but was suppressed in the intervention group. The saliva pH did not show a significant change throughout RT in either group. The incidence of oral candidiasis in the intervention group tended to be lower than that in the control group.

CONCLUSION

This study suggested that prophylactic use of a miconazole oral patch was effective in suppressing the growth of C. albicans count in saliva during RT for head and neck cancer.

Late Oral Complications Caused by Head and Neck Radiotherapy: Clinical and Laboratory Study

Objectives

The aim of presented cross-sectional and observational study was to determine the prevalence of late oral complications of patients with head and neck cancer who underwent radiotherapy, by clinical and laboratory analyses.

Material and Methods

Fifty-five patients, 43 (78.2%) men and 12 (21.8%) women, mean age 60; range 38 to 87 years, who have completed radiotherapy for head and neck cancer for at least 6 months were enrolled. The presence of xerostomia, hyposalivation, oral candidiasis, and type of oral yeasts were correlated with post-radiotherapy period. A control group, age and gender matched, was used for comparisons. The Pearson’s Chi-square or Fischer’s exact test was used at a significance level of 5%.

Results

The mean post-radiotherapy period was 32 months. The oral complications found were xerostomia (45/55, [81.8%]), hyposalivation (44/55 [80%]) and oral candidiasis (15/55 [27.2%]). Xerostomia and hyposalivation was statistically higher in the study group when compared to the control group (P < 0.05). The presence of yeast occurred in 39 (70.9%) of the patients in the study group, and Candida albicans was the most prevalent etiological agent in 25 (64.1%) of those patients (P < 0.05).

Conclusions

Xerostomia and hyposalivation were the more prevalent late oral complications related to radiotherapy. Oral candidiasis was also observed, although its prevalence was lower. The need for long-term dental follow-up of patients who underwent radiotherapy of the head and neck cancer is mandatory.

Mannan detecting C-type lectin receptor probes recognise immune epitopes with diverse chemical, spatial and phylogenetic heterogeneity in fungal cell walls

During the course of fungal infection, pathogen recognition by the innate immune system is critical to initiate efficient protective immune responses. The primary event that triggers immune responses is the binding of Pattern Recognition Receptors (PRRs), which are expressed at the surface of host immune cells, to Pathogen-Associated Molecular Patterns (PAMPs) located predominantly in the fungal cell wall. Most fungi have mannosylated PAMPs in their cell walls and these are recognized by a range of C-type lectin receptors (CTLs). However, the precise spatial distribution of the ligands that induce immune responses within the cell walls of fungi are not well defined. We used recombinant IgG Fc-CTLs fusions of three murine mannan detecting CTLs, including dectin-2, the mannose receptor (MR) carbohydrate recognition domains (CRDs) 4–7 (CRD4-7), and human DC-SIGN (hDC-SIGN) and of the β-1,3 glucan-binding lectin dectin-1 to map PRR ligands in the fungal cell wall of fungi grown in vitro in rich and minimal media. We show that epitopes of mannan-specific CTL receptors can be clustered or diffuse, superficial or buried in the inner cell wall. We demonstrate that PRR ligands do not correlate well with phylogenetic relationships between fungi, and that Fc-lectin binding discriminated between mannosides expressed on different cell morphologies of the same fungus. We also demonstrate CTL epitope differentiation during different phases of the growth cycle of Candida albicans and that MR and DC-SIGN labelled outer chain N-mannans whilst dectin-2 labelled core N-mannans displayed deeper in the cell wall. These immune receptor maps of fungal walls of in vitro grown cells therefore reveal remarkable spatial, temporal and chemical diversity, indicating that the triggering of immune recognition events originates from multiple physical origins at the fungal cell surface.

Invasive fungal infections remain an important health problem in immunocompromised patients. Immune recognition of fungal pathogens involves binding of specific cell wall components by pathogen recognition receptors (PRRs) and subsequent activation of immune defences. Some cell wall components are conserved among fungal species while other components are species-specific and phenotypically diverse. The fungal cell wall is dynamic and capable of changing its composition and organization when adapting to different growth niches and environmental stresses. Differences in the composition of the cell wall lead to differential immune recognition by the host. Understanding how changes in the cell wall composition affect recognition by PRRs is likely to be of major diagnostic and clinical relevance. Here we address this fundamental question using four soluble immune receptor-probes which recognize mannans and β-glucan in the cell wall. We use this novel methodology to demonstrate that mannan epitopes are differentially distributed in the inner and outer layers of fungal cell wall in a clustered or diffuse manner. Immune reactivity of fungal cell surfaces was not correlated with relatedness of different fungal species, and mannan-detecting receptor-probes discriminated between cell surface mannans generated by the same fungus growing under different conditions. These studies demonstrate that mannan-epitopes on fungal cell surfaces are differentially distributed within and between the cell walls of fungal pathogens.

Antimicrobial activity and chemical composition of essential oil from Helichrysum microphyllum Cambess. subsp. tyrrhenicum Bacch., Brullo & Giusso collected in South-West Sardinia

The aim of this study was to evaluate the chemical composition and the antimicrobial activity of essential oils of Helichrysum microphyllum subsp. tyrrhenicum collected in four different stations in South-Western Sardinia. The composition of the essential oils was determined by gas chromatography and gas chromatography/mass spectrometry. The oil samples showed different chromatographic profiles. The oil of the station 4 revealed the presence of significant amount of neryl acetate (33.6%); in oils from stations 1 and 2 we found γ-curcumene (28%) and in station 3 γ-curcumene (12%) and linalool (11%), while there was no trace of neryl acetate. Standard microbiological assays demonstrated that essential oils obtained by plants collected in station 1 and 2, very rich in curcumene, showed an interesting anticandidal activity, dose- and time-dependent, which is enhanced by sub-inhibitory concentrations of chitosan. Our results suggest that the essential oil of Helichrysum microphyllum subsp. tyrrhenicum, associated with chitosan in innovative formulations, could be considered as a therapeutic alternative in the treatment of Candida opportunistic infections. The results of this study shows that the chemotypization of the species examined could lead to their targeted clinical use, in a concept of a rational scientific aromatherapy.

A retrospective study of 606 cases of nasopharyngeal carcinoma with or without oropharyngeal candidiasis during radiotherapy

Background

To evaluate the clinical characteristics, treatment-related toxicities and survival in patients with nasopharyngeal carcinoma (NPC) with or without oropharyngealcandidiasis (OPC) during radiotherapy.

Methods

The current study was conducted with NPC patients undergoing radiotherapy at Sun Yat-Sen University Cancer Center between June 2011 and May 2012. A clinical diagnosis of candidiasis was determined on the basis of a positive potassium hydroxide (KOH) test and the presence of pseudomembranous (white) form of candidal overgrowth. The Cox proportional hazard regression model was used to test the association of OPC and related survival rates.

Results

Compared with the non-OPC group, the OPC group had significantly increased occurrence rates of grade 3–4 mucositis (14.5% vs. 7.4%, P = 0.049), anaemia (11.3% vs. 4.4%, P = 0.020), hepatotoxicity (4.8% vs. 1.1%, P = 0.021) and critical weight loss (85.5% vs. 56.6%, P<0.001) during radiotherapy. The OPC group had a significantly lower disease-free survival (DFS) (70.9% vs. 82.6%, P = 0.012), mainly as a result of a reduction in locoregional relapse-free survival (LRFS) (87.0%vs. 94.9%, P = 0.025). After stratification by T stage, the 5-year DFS in T3-4 patients were 82.0% and 68.8% in non-OPC and OPC groups, respectively (P = 0.022). Multivariate analyses indicated that OPC was a prognostic factor for LRFS and DFS.

Conclusions

OPC during radiotherapy may worsen the nutritional status of NPC patients according to weight loss and anaemia, leading to a negative impact on 5-year locoregional relapse-free survival and disease-specific survival. Further investigations are needed to explore whether prevention and treatment of OPC during radiotherapy will be useful.

Punica granatum Linn. prevention of oral candidiasis in patients undergoing anticancer treatment

Abstract Introduction Oral candidiasis is considered one of the complications of antineoplastic therapy of head and neck. Studies show that herbal medicine has proven to be a promising alternative for the treatment of candidiasis. Objective To evaluate the effectiveness of the gel Punica granatum Linn. in the prevention of oral candidiasis in patients undergoing radiotherapy with or without chemotherapy for squamous cell carcinoma of the head and neck, and adverse effects associated with its use. Material and method It was performed a clinical trial, double blind, in the period 2012-2013, with patients seen at a referral hospital for cancer treatment. The sample consisted of 17 patients who did not have signs nor symptoms of oral candidiasis. These patients were divided into two groups: experimental (n=11): composed of patients who used the gel Punica granatum Linn. 6.25% since the beginning of the anticancer treatment and completed a week after the end of the treatment regimen; control (n=6): for patients who used the gel Miconazol 2%, following the same guidelines of the previous group. Data were tabulated and analyzed using descriptive statistics, the chi-square test and calculation of continuing Yates correction (p<0.05). Result There was no oral candidiasis in 63.6% of patients in the experimental group and in none of the control group patients. Conclusion Most patients who used the experimental gel showed no clinical signs of fungal infection, and there was no association of adverse effects.

Supportive Management of Mucositis and Metabolic Derangements in Head and Neck Cancer Patients

Oral mucositis (OM) is among the most undesirable, painful, and expensive toxicities of cytotoxic cancer therapy, and is disheartening for patients and frustrating for caregivers. Accurate assessment of the incidence of OM has been elusive, but accumulating data suggests that reported OM frequency is significantly less than its actual occurrence. It has been suggested that over 90% of head and neck cancer (HNC) patients receiving radiotherapy (RT) with concurrent cisplatin experience severe OM with symptoms of extreme pain, mucosal ulceration and consequent limitations in swallowing and achieving adequate nutritional intake. This panoply of symptoms inevitably impacts a patients' quality of life and their willingness to continue treatment. In spite of all the advances made in understanding the pathophysiology of OM, there is still no prophylactic therapy with proven efficacy. Strategies to limit the extent of OM and to manage its symptomatology include basic oral care, supportive medications, nutritional support and targeting aggressive treatments to high-risk patients. This review focuses on OM recognition, preventive measurements, and symptom-management strategies.

Management of oropharyngeal mycosis in head and neck cancer occurring during (chemo) radiotherapy: an Italian radio-oncologist survey

AIMS AND BACKGROUND

Oropharyngeal candidiasis is a common disorder in head and neck cancer patients (HNCPs) who underwent (chemo)-radiotherapy. An Italian survey was conducted in order to investigate radiation oncologists' behavior in regard to diagnosis, prevention, and treatment of oral candidiasis.

METHODS AND STUDY DESIGN

Between April and May 2013, a national online 18-question survey was sent to major Italian radiotherapy centers.

RESULTS

All Italian regions were represented and 86 radiation oncologists were involved. Eighty-three percent of responders estimated that oropharyngeal candidiasis occurred in 30%-40% of their HNCPs. The majority of responders were able to recognize oral mycosis when it occurred in a localized pseudomembranous form and all responders agreed with the fact that oral candidiasis was always associated with mucositis. A prophylactic therapy was prescribed occasionally by 35% and routinely by 20% of responders. Forty percent prescribed an antifungal drug in the case of suspected mycotic infection and 20% waited for symptomatic clinical evidence before prescribing a therapy. In the presence of candidiasis, mainly topical fluconazole (59%) and itraconazole (36%) were prescribed. Concomitant chemo-radiotherapy was first identified as a risk factor for mycosis occurrence and development. Ninety-nine percent of responders believed that oral mycosis was associated with increased toxicity and 44% of them interrupted treatment due to candidiasis.

CONCLUSIONS

A variety of approaches to oropharyngeal candidiasis emerges from this survey; further clinical trials are necessary to identify the best approach for oral mycosis prevention and treatment and to establish specific international guidelines for HNCPs.

Epidemiology and prevalence of oropharyngeal candidiasis in Spanish patients with head and neck tumors undergoing radiotherapy treatment alone or in combination with chemotherapy

OBJECTIVE

To describe the oropharyngeal candidiasis (OPC) prevalence in Spanish patients with head and neck cancer undergoing radiotherapy, alone or combined with chemotherapy. Secondary objectives were to determine the prevalence of Candida species colonization, and to explore whether different Candida species colonizing the oral cavity and the treatment were associated with a higher prevalence of OPC.

METHODS

This is an observational, cross-sectional, multicentre study, conducted in Spanish radiation oncology units. Patients were diagnosed with head and neck cancer and started a radiotherapy treatment alone or combined with chemotherapy at the moment of their inclusion (N = 92).

RESULTS

The OPC prevalence was 26 %. The identification of colonizing pathogens was performed in 49 patients, and Candida albicans was the dominant yeast (69 %), while non-albicans Candida was only found in 15 patients (31 %). Patients with C. albicans colonization had a significant higher prevalence of OPC compared to patients colonized by non-albicans Candida (p = 0.0273), but no difference was found regarding the OPC prevalence in patients receiving only radiotherapy compared to patients with both radiotherapy and chemotherapy treatments.

CONCLUSIONS

Our data represent a step further in the knowledge of Candida species present in Spanish patients with head and neck tumors under radiation therapy. This is an essential step to manage the prophylaxis and treatment of OPC, since it might lead to severe clinical complications causing treatment interruption and, thus, representing a reduction in anti-tumor efficacy.

Models hosts for the study of oral candidiasis

Oral candidiasis is an opportunistic infection caused by yeast of the Candida genus, primarily Candida albicans. It is generally associated with predisposing factors such as the use of immunosuppressive agents, antibiotics, prostheses, and xerostomia. The development of research in animal models is extremely important for understanding the nature of the fungal pathogenicity, host interactions, and treatment of oral mucosal Candida infections. Many oral candidiasis models in rats and mice have been developed with antibiotic administration, induction of xerostomia, treatment with immunosuppressive agents, or the use of germ-free animals, and all these models has both benefits and limitations. Over the past decade, invertebrate model hosts, including Galleria mellonella, Caenorhabditis elegans, and Drosophila melanogaster, have been used for the study of Candida pathogenesis. These invertebrate systems offer a number of advantages over mammalian vertebrate models, predominantly because they allow the study of strain collections without the ethical considerations associated with studies in mammals. Thus, the invertebrate models may be useful to understanding of pathogenicity of Candida isolates from the oral cavity, interactions of oral microorganisms, and study of new antifungal compounds for oral candidiasis.

Evaluation of tissue engineered models of the oral mucosa to investigate oral candidiasis

Candida albicans is a commensal organism that can be isolated from the majority of healthy individuals. However, in certain susceptible individuals C. albicans can become pathogenic leading to the mucocutaneous infection; oral candidiasis. Murine models and in vitro monolayer cultures have generated some data on the likely virulence and host factors that contribute to oral candidiasis but these models have limitations. Recently, tissue engineered oral mucosal models have been developed to mimic the normal oral mucosa but little information is available on their true representation. In this study, we assessed the histological features of three different tissue engineered oral mucosal models compared to the normal oral mucosa and analysed both cell damage and cytokine release following infection with C. albicans. Models comprised of normal oral keratinocytes and a fibroblast-containing matrix displayed more similar immunohistological and proliferation characteristics to normal mucosa, compared to models composed of an oral carcinoma cell line. Although all models were invaded and damaged by C. albicans in a similar manner, the cytokine response was much more pronounced in models containing normal keratinocytes. These data suggest that models based on normal keratinocytes atop a fibroblast-containing connective tissue will significantly aid in dissecting the molecular pathogenesis of oral candidiasis.