ORAL YEAST INFECTIONS

by Seymour L. Gottlieb, BS, BDS, DDS, member of NOHA’s Professional Advisory Board, with a private practice in Dentistry in Northbrook, Illinois; former Research Assistant and Instructor, College of Dentistry, University of Illinois and Researcher in Microbiology, United States Public Health Service, Center for Disease Control.

The most common oral fungal infection is caused by the yeast Candida, which is a normal constituent of the digestive and vaginal tracts. Candida, also called Monilia, is the name for a large group of yeastlike fungi commonly found in nature. A particular yeast organism in this group, Monilia albicans, causes candidiasis (sometimes known as moniliasis). The organism infects the mouth and throat, especially of babies and the very elderly. In this form, it is called thrush. Candida species are assumed to cause disease by tissue invasion, by inducing a hypersensitive state, or by producing potent toxins. In individuals with compromised immune systems, Candida can cause a variety of opportunistic infections.

The most common oral fungal infection is caused by the yeast Candida, which is a normal constituent of the digestive and vaginal tracts. Candida, also called Monilia, is the name for a large group of yeastlike fungi commonly found in nature.

Signs

The four clinical forms of oral candidiasis are:
 
  • Moniliasis or thrush -- a smooth creamy white or yellow coating on any oral surface (When the surface is wiped off, a red underlying tissue is revealed.);
  • Erythematous -- red, peeling patches, most commonly on the palate and tongue;
  • Hyperplastic (chronic) -- extra tissue that cannot readily be wiped off and may appear discolored because of staining caused by foods or tobacco;
  • Angular cheilitis -- red cracks at the corners of the mouth often covered by a pseudo membrane. Angular cheilitis can occur with other forms of candidiasis or appear separately. Angular chelitis from oral candidiasis has to be differentiated from similar cracks caused by vitamin B complex deficiency, dysmenorrhea, lip licking, loss of teeth or their wear, or sun exposure.
 
 
 

Symptoms

Oral candidiasis may cause burning or painful sensations but most often is asymptomatic. Other symptoms that may be yeast connected include a craving for sugar, alcohol, or bread; digestive problems; fatigue; depression; and muscle or joint pains.

Causes

Oral candidiasis is initiated along with decreased host defense by a variety of different drug therapies, systemic diseases, or conditions that result in changes in the oral cavity. At one time oral fungal infections were rare in the dental office until broad-spectrum antibiotics, glucocorticosteroid preparations, birth control pills, and tricyclic antidepressants were developed.

 
 
  • Broad-spectrum antibiotics increase susceptibility to oral candidal infections by killing the beneficial gastrointestinal bacterial flora that naturally inhibit Candida, thus disrupting the normal balance of organisms in the gut. The introduction of antibiotics in the 1940s to combat infectious diseases was one of the important developments in medical treatment. However, some bacteria have become resistant to antibiotics. We saw an example of a similar occurrence when there was widespread use of DDT in the United States and some insects became resistant. While I was assigned to microbiological germ warfare defense work for the United States Public Health Service, Center for Disease Control, researcher friends at our laboratory discovered how flies, through generations and mutations, were able to change DDT to the inactive form DDE, which the insects could harmlessly metabolize. Antibiotics also, indiscriminately or repeatedly taken, destroy especially the weaker bacteria as well as their target organisms in the body. With proper temperature and nutritional conditions, one bacterium can reproduce to over 16 million in 24 hours. In 20 drops, saliva can have as many as10 million bacteria, most of them harmless. Thus, when the normal balance of organisms in the mouth and gastrointestinal tract is disrupted, the Candida organism can overgrow and become invasive.
  • Glucocorticosteroid preparations appear to lower resistance to Candida by suppressing our immunity, both the non-specific inflammatory response and the T-lymphocyte response (our cell-mediated immunity).
  • Birth control pills have hormonal effects that can lower a woman’s resistance to overgrowth of Candida.
  • Tricyclic antidepressants are associated with reduced salivary flow, which can lead to oral candidiasis.
 
 
 

There are systemic diseases in which oral Candida infections are more prevalent. These include diabetes mellitus, hypothyroidism, hypoadrenalism, and Sjogren’s syndrome (reduced saliva).

Dietary folate or iron deficiencies as well as radiation of the head and neck region may also predispose to candidiasis development. Reports indicate that iron-deficient subjects with candidal infections have a decrease in lymphocytes, the cells in the blood that are involved in immunity. Other studies show that the immune response can be restored when iron levels are normalized.

Most of these predisposing conditions cause decreased salivary flow and/or decreased excretion of immunoglobulins in the saliva. The latter decrease lowers the efficiency of the B-lymphocyte immunologic defense mechanism that should help control Candida infections. In addition, Candida growth in saliva is enhanced and the adhesive property of the yeast to oral tissue is increased by a high carbohydrate diet.

I often see denture stomatitis, which is a chronic inflammatory condition under dentures or removable partials. The inflammation can be caused by irritation or from an allergic response to the acrylic denture base material or candidal infection. The relatively acidic and anaerobic environment under the denture is ideal for yeast growth. The denture or partial must be soaked in a nystatin solution during treatment. Deeper infections in tissue are signs that the yeast organism has become systemic and the patient should be referred to a medical specialist. A biopsy can determine if such a deep fungal infection is present.

Treatment

The oral signs that most commonly occur in my years of practice are heavily coated, discolored tongues or cracking at the corners of the lips. Vitamins and acidophilus are immediately prescribed plus a therapeutic diet and effective drug therapy, along with a diary taken of everything they eat or take in by mouth for five days.

Following are the drugs used in treatment:
 
  • Nystatin is an antifungal antibiotic made from another organism, Streptomyces noursei. It does not damage bacteria or viruses and is virtually non-toxic with negligible adverse reactions. It is most commonly used at the onset as it is effective both topically and orally. The yeast orgamism rarely develops resistance to nystatin. Trade names include Mycostatin®, Mycolog II®, and Nilstat®, in addition to generic preparations.
  • Amphotericin B (Fungizone®, Adria®, and Apothecon®) is a broad spectrum drug but exhibits toxicity and some side effects Therefore, it is used for the more invasive form of Candida. Blood tests should be used to monitor for liver damage. Creams and ointments, based on amphotericin B, are available for the corners of the mouth (angular cheilitis) with no signs of systemic toxicity.
  • Ketoconazole preparations are antifungals that cause changes in the fungus cell wall and bind with the organisms. These are Mycelex®, Monistat®, and Nizoral®.
  • Candicidin (Candeptin®) is an antifungal antibiotic made from another streptomycin strain.
  • Triazoles (Diflucan® and Sporanox®) act similarly to ketoconazole but are less disruptive to the patient and are rapidly absorbed. However, they are more costly.
 
 
 
 

Other remedies include: grapefruit seed extract, capricin tea, homeopathic Candida silicea, artemisia, grape seed oil, and gentian. FOS (fructo-oligosaccharide) is an insoluble fiber that acts as a food source for the healthful bifidus bacteria in the intestine. These bacteria ferment this carbohydrate resulting in fatty acids that are used for the intestinal epithelial cells, which enhance water and mineral absorption.

A prescribed therapeutic diet is necessary during treatment to prevent the invasive re-growth of the yeast organism. The diet should include avoiding alcohol, sugar, white flour, and refined or processed carbohydrates. In addition, in order to provide optimal treatment results, fruit and milk, as well as any foods that have been dried, fermented, or that contain yeasts or molds, must be excluded. Also, sterilizing your tooth brush in household hydrogen peroxide or 70 percent alcohol for a few minutes will prevent its re-contamination of the mouth with organisms that survive on the brush.

Taking lacto bacillus acidophilus is safe and inexpensive. It in itself is not a cure but can help provide a healthier and better recovery from a yeast infection. Each use of antibiotics can alter the balance of bacteria. A diet adequate in important nutrients aids this balance for health.

Article from NOHA NEWS, Vol. XX, No. 3, Summer 1995, pages 4-5.