Tongue pain: burning mouth syndrome vs Candida- associated lesion

Management of Burning Mouth Syndrome

This article provides an update for the practicing dentist and/or oral and maxillofacial surgeon on the recognition, identification, and treatment of burning mouth syndrome (BMS). We discuss the most common clinical findings and most common causes of BMS. This article provides a classification flowchart that assists the practitioner in diagnosing and classifying BMS. The article then discusses the pathophysiology and treatment of BMS updated in the literature from the latest studies and reviews. Treatment can vary from topical or systemic medication to behavioral therapy.

Efficacy of oral nystatin treatment for patients with oral mucosal dysesthesia but without objective oral mucosal manifestations and necessity of Candida culture test before oral nystatin treatment

Background/purpose

Materials and methods

Results

Conclusion

Clinical Characteristics and Relevance of Oral Candida Biofilm in Tongue Smears

Dimorphic Candida exist as commensal yeast carriages or infiltrate hyphae in the oral cavity. Here, we investigated the clinical relevance of Candida hyphae in non-pseudomembranous oral candidiasis (OC) by smears of tongue biofilms. We conducted a retrospective study of 2829 patients who had had tongue smears regardless of OC suspicion. Clinical characteristics were evaluated using a novel method of assessing hyphae. Clinical factors (moderate/severe stimulated pain, pain aggravated by stimulation, tongue dorsum appearance and initial topical antifungal use) were highly significant in the high-grade hyphae group but were statistically similar in the low-grade hyphae and non-observed hyphae group, suggesting low-grade hyphae infection as a subclinical OC state. In addition to erythematous candidiasis (EC), a new subtype named "morphologically normal symptomatic candidiasis" (MNSC) with specific pain patterns and normal tongue morphology was identified. MNSC had a significantly higher proportion of moderate and severe stimulated pain cases than EC. Low unstimulated salivary flow rate (<0.1 mL/min) was found to be a common risk factor in MNSC and EC. In non-pseudomembranous OC, pain patterns were dependent on Candida hyphae degree regardless of tongue dorsum morphology. Morphologic differences seen in high-grade hyphae infection were not associated with systemic diseases or nutritional deficiencies.

Geriatric oral and maxillofacial dysfunctions in the context of geriatric syndrome

OBJECTIVES

To propose the application of the concept of geriatric syndrome for common geriatric oral and maxillofacial dysfunctions and to suggest the necessity of developing effective evaluation methods for oral and maxillofacial frailty.

DESIGN

The concepts of frailty and geriatric syndrome based on multi-morbidity and polypharmacy were applied to five common geriatric oral medicinal dysfunctional problems: salivary gland hypofunction (dry mouth), chronic oral mucosal pain disorders (burning mouth symptoms), taste disorders (taste disturbances), swallowing disorders (dysphagia), and oral and maxillofacial movement disorders (oromandibular dyskinesia and dystonia).

RESULTS

Each of the dysfunctions is caused by various kinds of diseases and/or conditions and medications, thus the concept of geriatric syndrome could be applied. These dysfunctions, suggested as components of oral and maxillofacial geriatric syndrome, are associated and interacted with each other in a complexity of vicious cycle. The resulting functional impairments caused by this syndrome can cause oral and maxillofacial frailty.

CONCLUSIONS

Geriatric oral and maxillofacial dysfunctions could be better appreciated in the context of geriatric syndrome. The development of effective methods for evaluating the severity of these dysfunctions and the resulting frailty is essential.

Elimination of oral candidiasis may increase stimulated whole salivary flow rate

OBJECTIVES

Candida infections are frequently encountered fungal infections in the oral mucosa. This study aimed to evaluate the effect of eliminating Candida spp. on stimulated whole salivary flow rate (SWS) in patients with oral candidiasis.

SUBJECTS AND METHODS

This study involved 66 patients with oral candidiasis. Fifty-two consecutive patients, successfully treated by antifungal therapy, were available to examine the effect of elimination of oral Candida spp. on SWS (success group); the 14 patients who tested positive for Candida after therapy were retrospectively included (control group). SWS were used to measure saliva production. Moreover, tongue pain and xerostomia were evaluated using visual analog score (VAS).

RESULTS

By eliminating oral Candida spp., SWS significantly increased in the success group after antifungal therapy [SWS: mean value 0.89±0.51ml/min (median 0.82ml/min: 0.15-2.14) to mean value 1.16±0.58ml/min (median 1.05ml/min: 0.2-2.93), P<0.001]. Furthermore, VAS scores for subjective tongue pain and xerostomia were significantly decreased compared with those before therapy in the success group [xerostomia: mean value 52.5±28.8 (median 53: 9-100) to 24.2±1.6 (median 17: 0-70), tongue pain: mean value 52.6±27.2 (median 56: 1-93) to 15.3±18.0 (median 9: 0-62). P<0.001]. There was no significant difference in SWS, subjective tongue pain, or xerostomia in the control group after antifungal therapy. [SWS: mean value 1.08±0.83ml/min (median 0.69ml/min: 0.2-2.7) to 0.98±0.59ml/min (median 0.8ml/min: 0.45-2.5), P=0.65], [xerostomia: mean value 62.8±5.3 (median 62: 28-70) to 64.0±8.8 (median 64: 56-73), P=0.58, tongue pain: mean value 64.3±18.6 (median 67: 31-87) to 58.4±20.0 (median 8: 20-78), respectively; P=0.24] CONCLUSION: Our study demonstrated that SWS may increase by eliminating oral Candida spp. in patients with oral candidiasis.

In vitro and in vivo removal of oral Candida from the denture base

OBJECTIVES

To clarify the effectiveness of ultrasonic cleaning for removing Candida lodged in the denture base.

MATERIALS AND METHODS

In vitro - Specimens of acrylic resin for denture plates contaminated with Candida cells were ultrasonically cleaned for 30 min. Washings were sampled every 5 min and cultured to investigate residual contamination, measured as colony forming units/ml, and the surfaces of the specimens were subjected to low-vacuum scanning electron microscopy (LV-SEM). In vivo - A total of 24 maxillary denture bases were brushed for 2 min under running tap water, then ultrasonically cleaned for 30 min. The washings were sampled every 5 min and cultured to investigate residual contamination.

RESULTS

In vitro - Maximum removal was achieved during the first 5 min of cleaning, with the mean CFU/ml counts significantly declining over time. More than 85% of all Candida was removed within the first 15 min in specimens inoculated with phosphate-buffered saline suspensions of Candida albicans and Candida glabrata. LV-SEM revealed a decreased number of Candida on the surface of the specimens after 30 min of ultrasonic cleaning. In vivo - Maximum removal was achieved during the first 5 min of cleaning, then the mean CFU/ml count significantly declined during the first 10 min. Ultrasonic cleaning for 15 min removed 88.4% of Candida species from the denture base.

CONCLUSIONS

Ultrasonic cleaning is a reliable and simple method for removing Candida lodged in the denture base.

Effects of surface roughness and dimorphism on the adhesion of Candida albicans to the surface of resins: scanning electron microscope analyses of mode and number of adhesions

AIM

Candida albicans is a common oral fungus but can cause serious conditions such as Candida stomatitis. We investigated C. albicans adhesion to the surface of denture-base resins at two growth phases.

METHODS

Fungal suspensions of logarithmic (9 h) and stationary phase (24 h) C. albicans (JCM2085) were used. Scanning electron microscopy (SEM) confirmed that yeast and mycelial forms were predominant in 9-h and 24-h cultures, respectively. Resin strips were polished to three surface roughness levels (Ra 3.2 μm, Ra 0.48 μm and Ra 0.06 μm) and were then immersed in C. albicans suspensions for both phases. The SEM images were taken at five sites on each strip.

RESULTS

Adhesion of mycelial-form C. albicans on rough surfaces (Ra = 3.2) was 2.2 times higher than on smooth surfaces (Ra = 0.06; 7030 vs 3580 adhesions/mm(2), P < 0.01). The hyphae of these mycelial forms fully penetrated the surface cracks. Fewer adhesions occurred for yeast-form C. albicans, regardless of surface type (440-620 adhesions/mm(2), P = n.s.).

CONCLUSION

Adhesion of yeast-form C. albicans was indifferent to surface roughness. In contrast, mycelial adhesion increased with surface roughness of the resin because mycelia infiltrated the minute protuberances on rough surfaces.

A prospective, randomized study on the efficacy of tongue protector in patients with burning mouth syndrome

OBJECTIVE

To apply a tongue protector with habit-modifying therapy through self-control, in the patients with burning mouth syndrome (BMS).

METHODS

A prospective, randomized study was made of 65 consecutive patients with BMS. Fifty subjects were randomized to two groups: group A (informed) and group B (informed and the application of a tongue protector). The symptoms were evaluated by VAS, whereas the psychological profile was assessed using the HAD, with application of the quality of life questionnaires SF-36 and OHIP-49. The duration of treatment was 2 months.

RESULTS

Fifty patients (46 females and 4 males) completed the study. The VAS scores in group B were 8.2 at baseline and 4.5 after 2 months. The respective scores in group A were 7.1 and 5.6 - the differences between the two groups being significant (P < 0.001). In group B the OHIP-49 yielded lower scores for most of the scales, with significant differences vs group A. In group B the SF 36 yielded significant differences vs group A in physical role, bodily pain, general health and emotional role.

CONCLUSIONS

Parafunctional traumatism of the tongue should be taken into account in the pathogenesis of BMS with a view to exploring new therapeutic options.

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

OBJECTIVE: To investigate oral candidiasis in patients with head and neck cancer before, during, and after radiation therapy, and to explore its association with clinical oropharyngeal symptoms.

STUDY DESIGN: A cohort study.

SETTING: University hospital.

SUBJECTS AND METHODS: Subjects who received radiation therapy (RT) for the treatment of head and neck cancer were divided into two groups: an oral cavity irradiated group (OIRR group, n = 29) and an oral cavity nonirradiated group (ONIRR group, n = 17). A control group consisted of 18 healthy subjects. Patients were examined for signs of oral candidiasis before, during, immediately after, and one month after RT. Mouth and throat soreness (MTS), dysphagia, and xerostomia were evaluated by self-reported questionnaires, and associations between oral candidiasis and these symptoms were analyzed.

RESULTS: The incidence of oral candidiasis during RT was significantly higher in the OIRR group (55.2%) than in the ONIRR group (11.8%). Similarly, the occurrence of xerostomia during RT was significantly higher in the OIRR group (86.2%) than in the ONIRR group (52.9%). In the OIRR group, the mean MTS score at the 20th fraction of RT was significantly higher in patients with candidiasis (mean ± SD, 5.8 ± 2.1) than in those with RT-induced mucositis without candidiasis (3.7 ± 2.0). In the OIRR group, 65.2 percent of patients who experienced dysphagia developed oral candidiasis, compared with only 10 percent in the ONIRR group.

CONCLUSION: Oral candidiasis concurrent with oral mucositis due to RT may increase oropharyngeal discomfort during RT.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

A systematic review of oral fungal infections in patients receiving cancer therapy

PURPOSE

The aims of this systematic review were to determine, in patients receiving cancer therapy, the prevalence of clinical oral fungal infection and fungal colonization, to determine the impact on quality of life and cost of care, and to review current management strategies for oral fungal infections.

METHODS

Thirty-nine articles that met the inclusion/exclusion criteria were independently reviewed by two calibrated reviewers, each using a standard form. Information was extracted on a number of variables, including study design, study population, sample size, interventions, blinding, outcome measures, methods, results, and conclusions for each article. Areas of discrepancy between the two reviews were resolved by consensus. Studies were weighted as to the quality of the study design, and recommendations were based on the relative strength of each paper. Statistical analyses were performed to determine the weighted prevalence of clinical oral fungal infection and fungal colonization.

RESULTS

For all cancer treatments, the weighted prevalence of clinical oral fungal infection was found to be 7.5% pre-treatment, 39.1% during treatment, and 32.6% after the end of cancer therapy. Head and neck radiotherapy and chemotherapy were each independently associated with a significantly increased risk for oral fungal infection. For all cancer treatments, the prevalence of oral colonization with fungal organisms was 48.2% before treatment, 72.2% during treatment, and 70.1% after treatment. The prophylactic use of fluconazole during cancer therapy resulted in a prevalence of clinical fungal infection of 1.9%. No information specific to oral fungal infections was found on quality of life or cost of care.

CONCLUSIONS

There is an increased risk of clinically significant oral fungal infection during cancer therapy. Systemic antifungals are effective in the prevention of clinical oral fungal infection in patients receiving cancer therapy. Currently available topical antifungal agents are less efficacious, suggesting a need for better topical agents.

Impact of ageing and drug consumption on oral health

The impact of ageing on oral health and salivary flow is usually over-estimated possibly because of the high frequency of polypharmacy observed in this subset of patients. Understanding the physiological changes and treatment-related oral complications of older patients is essential to promote accurate management of symptoms and improve their quality of life. The current paper reviews age-related physiological chances in salivary glands and the effect of polypharmacy on oral health, focusing on xerostomia and hyposalivation.