Fluconazole mouthrinses for oral candidiasis in postirradiation, transplant, and other patients

In Vitro Impact of Fluconazole on Oral Microbial Communities, Bacterial Growth, and Biofilm Formation

Antifungal agents are widely used to specifically eliminate infections by fungal pathogens. However, the specificity of antifungal agents has been challenged by a few studies demonstrating antibacterial inhibitory effects against Mycobacteria and Streptomyces species. Here, we evaluated for the first time the potential effect of fluconazole, the most clinically used antifungal agent, on a human oral microbiota biofilm model. The results showed that biofilm viability on blood and mitis salivarius agar media was increased over time in the presence of fluconazole at clinically relevant concentrations, despite a reduction in biomass. Targeted PCR revealed a higher abundance of Veillonella atypica, Veillonella dispar, and Lactobacillus spp. in the fluconazole-treated samples compared to the control, while Fusobacterium nucleatum was reduced and Streptococcus spp were not significantly affected. Further, we tested the potential impact of fluconazole using single-species models. Our results, using Streptococcus mutans and Streptococcus mitis luciferase reporters, showed that S. mutans planktonic growth was not significantly affected by fluconazole, whereas for S. mitis, planktonic growth, but not biofilm viability, was inhibited at the highest concentration. Fluconazole's effects on S. mitis biofilm biomass were concentration and time dependent. Exposure for 48 h to the highest concentration of fluconazole was associated with S. mitis biofilms with the most increased biomass. Potential growth inhibitory effects were further tested using four non-streptococcal species. Among these, the planktonic growth of both Escherichia coli and Granulicatella adiacens was inhibited by fluconazole. The data indicate bacterial responses to fluconazole that extend to a broader range of bacterial species than previously anticipated from the literature, with the potential to disturb biofilm communities.

Oral management strategies for radiotherapy of head and neck cancer

Radiotherapy, often with concomitant chemotherapy, has a significant role in the management of head and neck cancer, however, radiotherapy induces adverse events include oral mucositis, hyposalivation, loss of taste, dental caries, osteoradionecrosis, and trismus, all of which have an impact on patients' quality of life. Therefore, it is necessary to implement oral management strategies prior to the initiation of radiotherapy in patients with head and neck cancer. Since 2014, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines) have enumerated the "Principles of Dental Evaluation and Management (DENT-A)" in the section on head and neck cancers, however, oral management was not explained in detail. Oral management has not been achieved a consensus protocol. The aim of this literature is to show that oral management strategy include removal infected teeth before the start of radiotherapy to prevent osteoradionecrosis, oral care for preventing severe oral mucositis to support patient complete radiotherapy during radiotherapy, and prevent of dental caries followed by osteoradionecrosis after radiotherapy.

Dynamics of Mono- and Dual-Species Biofilm Formation and Interactions Between Paracoccidioides brasiliensis and Candida albicans

The oral cavity is a highly diverse microbial environment in which microorganisms interact with each other, growing as biofilms on biotic and abiotic surfaces. Understanding the interaction among oral microbiota counterparts is pivotal for clarifying the pathogenesis of oral diseases. Candida spp. is one of the most abundant fungi in the oral mycobiome with the ability to cause severe soft tissue lesions under certain conditions. Paracoccidioides spp., the causative agent of paracoccidioidomycosis, may also colonize the oral cavity leading to soft tissue damage. It was hypothesized that both fungi can interact with each other, increasing the growth of the biofilm and its virulence, which in turn can lead to a more aggressive infectivity. Therefore, this study aimed to evaluate the dynamics of mono- and dual-species biofilm growth of Paracoccidioides brasiliensis and Candida albicans and their infectivity using the Galleria mellonella model. Biomass and fungi metabolic activity were determined by the crystal violet and the tetrazolium salt reduction tests (XTT), respectively, and the colony-forming unit (CFU) was obtained by plating. Biofilm structure was characterized by both scanning electronic- and confocal laser scanning- microscopy techniques. Survival analysis of G. mellonella was evaluated to assess infectivity. Our results showed that dual-species biofilm with P. brasiliensis plus C. albicans presented a higher biomass, higher metabolic activity and CFU than their mono-species biofilms. Furthermore, G. mellonella larvae infected with P. brasiliensis plus C. albicans presented a decrease in the survival rate compared to those infected with P. brasiliensis or C. albicans, mainly in the form of biofilms. Our data indicate that P. brasiliensis and C. albicans co-existence is likely to occur on oral mucosal biofilms, as per in vitro and in vivo analysis. These data further widen the knowledge associated with the dynamics of fungal biofilm growth that can potentially lead to the discovery of new therapeutic strategies for these infections.

Bacterial-derived exopolysaccharides enhance antifungal drug tolerance in a cross-kingdom oral biofilm

Fungal-bacterial interactions generate unique biofilms that cause many infections in humans. Candida albicans interact with Streptococcus mutans in dental biofilms associated with severe childhood tooth-decay, a prevalent pediatric oral disease. Current modalities are ineffective and primarily based on antimicrobial monotherapies despite the polymicrobial nature of the infection. Here, we show that the combination of clinically used topical antifungal fluconazole with povidone iodine (PI) can completely suppress C. albicans carriage and mixed-biofilm formation without increasing bacterial killing activity in vivo. We unexpectedly found that the inclusion of PI enhanced fluconazole efficacy by potently disrupting the assembly of a protective bacterial exopolysaccharide (EPS) matrix through inhibition of α-glucan synthesis by S. mutans exoenzyme (GtfB) bound on the fungal surface. Further analyses revealed that the EPS produced in situ directly bind and sequester fluconazole, reducing uptake and intracellular transportation of the drug. Conversely, inhibition of GtfB activity by PI, enzymatic degradation of the α-glucan matrix or co-culturing with gtfB-defective S. mutans re-established antifungal susceptibility. Hence, topical antifungal has limitations in mixed oral biofilms due to enhanced C. albicans tolerance to fluconazole afforded by the shielding effect of bacterial-derived EPS. The data provide new insights for treatment of C. albicans in cross-kingdom biofilms, indicating that EPS inhibitors may be required for enhanced killing efficacy and optimal anti-biofilm activity.

Current treatment of oral candidiasis: A literature review

Candidiasis or oral candidosis is one of the most common human opportunistic fungal infections of the oral cavity. This pathology has a wide variety of treatment which has been studied until these days. The present study offers a literature review on the treatment of oral candidiasis, with the purpose of establish which treatment is the most suitable in each case. Searching the 24 latest articles about treatment of candidiasis it concluded that the incidence depends on the type of the candidiasis and the virulence of the infection. Although nystatin and amphotericin b were the most drugs used locally, fluconazole oral suspension is proving to be a very effective drug in the treatment of oral candidiasis. Fluconazole was found to be the drug of choice as a systemic treatment of oral candidiasis. Due to its good antifungal properties, its high acceptance of the patient and its efficacy compared with other antifungal drugs. But this drug is not always effective, so we need to evaluate and distinguish others like itraconazole or ketoconazole, in that cases when Candida strains resist to fluconazole.

Key words:Candidiasis, treatment, miconazole, fluconazole, nystatin.

Pediatric soft tissue oral lesions

This article provides an overview of common color changes and soft tissue oral nodular abnormalities in children and adolescents. The clinical presentation and treatment options to address these conditions are presented in a concise approach, highlighting key features relevant to the oral health care professional.

Review of the complications associated with treatment of oropharyngeal cancer: a guide for the dental practitioner

OBJECTIVES

Oropharyngeal cancer (OPC) is the sixth most common cancer worldwide. Focus on risk factors, improved diagnostic methods and effective management strategies have made it possible to successfully treat OPC. However, the 5-year survival rate has not improved for several years due to multiple treatment complications, tissue morbidity, loss of function, and diminished quality of life. Survivors are faced with complications like oral mucositis, hyposalivation, osteoradionecrosis, tissue fibrosis, morbidity from jaw resection, disfigurement, and loss of function that further diminish quality of life. The aim of this review is to highlight major complications associated with treatment of OPC via a literature search and review of available options for identification and management of these complications.

DATA SOURCES

Relevant publications on oral complications of OPC therapy were thoroughly reviewed from the literature published between the years 1988 and 2012. We evaluated reported incidence, prevalence, and risk factors for oral complications of chemotherapy and radiotherapy for OPC. The authors conducted an electronic search using English language databases, namely PubMed Plus, Medline (Pre-Medline and Medline), Cochrane Database of Systematic Reviews (evidence-based medicine), Dentistry & Oral Sciences Source, A ccessScience, Embase, Evidence-Based Medicine Reviews Multifile, Google Scholar, ISI Journal Citation Reports, and Ovid Multi-Database.

CONCLUSION

We identified the most common complications associated with the treatment of oral cancers. Based on the information gathered, there is evidence that survival of OPC extends beyond eradication of the diseased tissue. Understanding the potential treatment complications and utilizing available resources to prevent and minimize them are important. Caring for OPC survivors should be a multidisciplinary team approach involving the dentist, oncologist, internist, and social worker to improve the currently stagnant 5-year survival rate of OPC. More emphasis on improved quality of life after elimination of the cancer will ultimately improve OPC survivorship.

Oropharyngeal candidiasis in head and neck cancer patients treated with radiation: update 2011

BACKGROUND

Oropharyngeal candidiasis (OPC) is a major cause of morbidity in patients with malignancies. It is a common complication of head and neck radiation therapy and can result in pain, dysgeusia (taste changes), anorexia, malnutrition, and esophageal or systemic dissemination. Clinicians should be aware of current epidemiology, elements of diagnosis, and therapeutic trials guiding the recent recommendations for prophylaxis and management of OPC, a disease often incorrectly perceived as benign.

METHODS

This review discusses OPC with focus in head and neck cancer patients receiving radiotherapy.

RESULTS

Local treatments are recommended as first-line therapy in milder forms of OPC. In the setting of local therapy, products that provide prolonged contact time and are not sucrose sweetened may result in successful prevention and management with low risk of oral/dental complications.

CONCLUSION

Diagnosis and management of OPC is required in head and neck cancer patients treated with radiation. Local therapy is suggested as first-line treatment for OPC, unless severe clinical infection or high risk immune suppression necessitate systemic therapy. The availability of effective locally delivered (topical) medications may provide potential for prophylaxis for carriers of Candida species in head and cancer patients during radiation therapy.

Comparison of efficacy of fluconazole mouthrinse and clotrimazole mouthpaint in the treatment of oral candidiasis

Candidiasis is by far the most common oral fungal infection in humans and has a variety of clinical features. It is considered to be an opportunistic infection, affecting individuals who are debilitated by another disease. Fluconazole, one of the newer azoles available for systemic use and clotrimazole as a topical ointment are both shown to be effective in the treatment of oral candidiasis and are considered to be well tolerated and useful medications. No study has evaluated the comparison of clinical and mycological response of oral candidiasis to fluconazole mouthrinse and clotrimazole mouthpaint. The aim of this study was to evaluate the efficacy of fluconazole mouthrinse and compare it with clotrimazole mouthpaint in the treatment of oral candidiasis.

Treatment strategies for oropharyngeal candidiasis

BACKGROUND

Oropharyngeal candidiasis (OPC) is a common oral disease that may cause oral symptoms, lead to regional infection (e.g., esophageal candidiasis) and increase the risk of systemic fungal infection in the compromised host.

OBJECTIVE

Critical review of the literature of prevention and therapy.

METHODS

The literature was reviewed using PubMed, and specific keywords from the MeSH Database were used.

RESULTS/CONCLUSION

Management of OPC requires that the underlying risk factors of infection be diagnosed and managed whenever possible. Antimicrobials may be provided as topical or systemic therapy. Topical therapies may provide effective management for candidiasis in the non-compromised host and increase the control of colonization in the compromised host. Advances in prevention and management include new agents and improved mechanisms of topical drug delivery.

Medical management update: Non-Hodgkin lymphoma

Lymphoma is a heterogeneous malignancy of the lymphatic system characterized by proliferation of lymphoid cells or their precursors. Non-Hodgkin lymphoma (NHL) is associated with significant morbidity and is the seventh leading cause of death in the United States. Manifestations of NHL as well as complications of the disease and its management are frequently encountered in the head and neck region and often require specific treatment and modifications in the provision of oral health care. The purpose of this article is to review current concepts of the pathophysiology, as well as medical and oral health care management of NHL.

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.

Salivary secretion, taste and hyposalivation

Saliva has many essential functions. As the first digestive fluid in the alimentary canal, saliva is secreted in response to food, assisting intake and initiating the digestion of starch and lipids. During this process, saliva acts as a solvent of taste substances and affects taste sensitivity. Clinically, a more important role is in the maintenance of oral health, including the protection of teeth and mucosa from infections, maintenance of the milieu of taste receptors, and communication ability through speech. Variations in salivary flow can be affected, reversibly or irreversibly, by numerous physiological and pathological factors. Decreased salivary flow results in clinically significant oral discomfort that may manifest as increased caries, susceptibility to oral candidiasis, altered taste sensation or as a host of other problems. Hyposalivation is a condition that is frequently encountered in dental practice. The most common cause is the use of certain systemic medications, which put the elderly at greater risk because they are usually more medicated. Other causes include high doses of radiation and certain diseases such as Sjögren's syndrome. This article reviews the mechanism of salivary secretion, effect of saliva on taste, importance of saliva in oral health, and hyposalivation in relation to ageing, medicine and/or disease and management of hyposalivation.

Dental management of patients with bone marrow and solid organ transplantation

With advances in transplant science, an increasing number of people are undergoing and surviving hematopoietic stem cell and solid organ transplantation. Those transplant recipients are also living longer. This means that many dentists nowadays will occasionally treat patients who are anticipating or who have received a transplant. Dentists thus should be knowledgeable about issues related to this population. The dentist's role is important because transplant patients are especially vulnerable to infection, which can stem from poor oral and dental hygiene. This article provides dentists with an overview of transplant science and guidance for dentists treating transplant patients.

Emerging approaches for prophylaxis and management of oropharyngeal mucositis in cancer therapy

Oral mucositis is a common treatment-limiting side effect of cancer therapy that may have a significant impact on quality of life and on the cost of care. Oral mucositis is the most distressing complication of cancer therapy as reported by head and neck cancer patients, in patients receiving dose-dense myelosuppressive chemotherapy and in patients receiving haematopoietic stem cell transplant. Mucositis may increase the risk of local and systemic infection, particularly in myelosuppressed patients. Severe oral mucositis can lead to the need to interrupt or discontinue cancer therapy, and thus may impact cure of the primary disease. Current care of patients with mucositis is essentially palliative, and includes appropriate oral hygiene, nonirritating diet and oral care products, topical palliative mouth rinses, topical anaesthetics and use of systemic opioid analgesics. Emerging approaches for prevention and treatment of oral mucositis are developing based on an increasing understanding of the pathobiology of mucosal damage and repair. New interventions are expected to be administered based on the mechanisms of initiation, progression and resolution of the condition. The approval by the FDA of keratinocyte growth factor (palifermin; Amgen) in 2004 represents a new step in prevention of oral mucositis in stem cell transplant patients based on the increasing understanding of the pathogenesis of mucositis. Progress in the prevention and management of mucositis will improve quality of life, reduce cost of care and facilitate completion of more intensive cancer chemotherapy and radiotherapy protocols. Improved management of mucositis may allow implementation of cancer treatment protocols that are currently excessively mucotoxic, but have potentially higher cure rates of the malignant disease.

Oral candidiasis prevention in transplantation patients: a comparative study

AIM

Oral candidiasis occurs commonly in haematopoietic -stem cell transplantation (HSCT) patients carrying a risk of systemic candidemia and mortality. The aim of this pilot study was to design an effective protocol that prevents oral candidiasis and improves tolerability.

METHODS

A prospective, randomized, longitudinal study with two treatment groups, (A) chlorhexidine (CHX) and (B) CHX combined with medium-dose amphotericin B (AMB), was performed. The investigators were blinded to the treatment arm.

RESULTS

No clinical signs of oral candidiasis were observed in any of the 20 patients. All patients experienced neutropenia and were treated with antibiotics. The duration of antibiotic treatment was longer in group A than that in group B. The difference in systemic anti-fungal treatment was insignificant. Compliance was achieved in both groups, although tolerability was better in group A than that in group B.

CONCLUSION

Effective oral anti-fungal prevention based on topical AMB was suggested. CHX mouthwash was also suggested to be effective as a single topical agent for the prevention of oral candidiasis in HSCT patients. The combination of topical CHX and medium-dose AMB-prophylactic protocol may achieve the same level of candidial prevention with better tolerability than that by AMB alone. More research is warranted.

Xerostomia Secondary to Sj??gren???s Syndrome in the Elderly

Xerostomia is a common symptom in the elderly population. Studies have suggested that the underlying cause of approximately 40% of xerostomia in the elderly is Sjögren's syndrome. Although it is highly prevalent among middle-aged individuals, elderly patients account for up to 20% of Sjögren's syndrome cases. Sjögren's syndrome is a multisystem exocrinopathy characterised by dry mouth and dry eyes with wide-ranging extraglandular involvement. The exocrine manifestations of Sjögren's syndrome affect the mouth, eyes, nose, ears, skin, vagina and the entire respiratory and gastrointestinal systems. The nonexocrine involvement may include the joints, thyroid gland, liver, kidneys and the musculoskeletal, vascular and central nervous systems. Currently, the mechanism(s) of development and progression of Sjögren's syndrome is/are not clear. Inflammation and lymphocytic infiltration of the exocrine glands is a classical feature of Sjögren's syndrome. During the progression of the disease, the acinar cells of the exocrine glands are replaced by fibrosis, rendering the glands nonfunctional. Sjögren's syndrome remains one of the most underdiagnosed conditions, particularly in the elderly population, because the cardinal sicca symptoms, which are the hallmark of the disease, are frequently attributed to aging and/or medications, which consequently delays the diagnosis. This delay in diagnosis imposes significant physical, psychological and economic burdens on elderly patients. The diagnosis of Sjögren's syndrome requires evaluation of both the exocrine and nonexocrine components of the disease. Management of Sjögren's syndrome requires collaboration by the primary-care physician, rheumatologist, ophthalmologist and dentist. This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome with special emphasis on the oral component of the disease.

Cytotoxic drugs, radiotherapy and oral candidiasis

The increased incidence of oral candidiasis in patients with malignancies stems partly from the systemic disease itself and, partly from the therapeutic measures such as cytotoxic and other immunosuppressive drugs and radiotherapy they receive during management of such malignancies. In this review we discuss the clinical and laboratory findings on the relationship between cytotoxics, radiotherapy and oral candidiasis, possible mechanisms of pathogenicity following such therapy, as well as precautions that could be taken to minimize such recalcitrant yeast infections.