Oral Candida Infection in Psoriatic Patients Treated with IL17A Inhibitors: Report of 3 Cases and a Comprehensive Review of the Literature

An intact and fully functional immune system plays a crucial role in the prevention of several infectious diseases. Interleukin (IL)17 is significantly involved in oral mucosa immunity against several antigens and microorganisms, including Candida albicans (CA). Herein, we present three cases of oral candidiasis (OC) related to the use of an IL17A inhibitor for psoriasis. Three psoriatic individuals presented for evaluation of widespread symptomatic oral lesions temporally correlated with the onset of IL17A inhibitors (secukinumab in two patients and brodalumab in one patient). Clinical examination revealed either partially removable white plaques in an erythematous background (case #1) or diffuse erythematous lesions (cases #2 and 3) involving several areas of the oral mucosa. Cytology smear, accompanied by histopathologic examination in case #1, confirmed the clinical impression of OC in all three cases. All patients received antifungal therapy with satisfactory clinical response. No discontinuation of the antipsoriatic regimen was recommended, but all patients were advised to remain under monitoring for possible OC relapses. During the last few years, new systemic biologic agents targeting IL17 have been used for the management of variable immune-mediated diseases. Few clinical trials and scarce case reports have shown that these medications place individuals at high risk of developing candidiasis. We propose that patients treated with these medications should be at close monitoring for the development of OC and, if it occurs, receive appropriate management.

Giant cell arteritis complicated by tongue necrosis and bilateral cerebellar ischaemic stroke

Giant cell arteritis (GCA) typically presents with headache, scalp tenderness or visual disturbance. Other symptoms include orofacial pain, constitutional symptoms and ischaemic stroke. An 81-year-old woman with a background of type-2 diabetes and hypertension presented with headache, oral pain and right visual loss. Examination showed hypertension, nodular temporal arteries, reduced visual acuity and suspected oral candida. Inflammatory markers were raised and she was diagnosed with GCA and commenced on corticosteroids. During treatment she developed tongue ulceration, then acute vertigo and incoordination with nystagmus and ataxia. Neuroimaging confirmed bilateral, cerebellar ischaemic strokes and temporal artery biopsy was consistent with GCA. With corticosteroids and secondary prevention of stroke measures she is now functionally independent. Oral pain is an uncommon symptom of GCA and delays in recognition may lead to catastrophic consequences. Clinicians should be aware of uncommon presentations and to optimise additional ischaemic stroke risk-factors.

Anti-Biofilm Formation of an Adhesive Containing Calcium Salts of Acidic Monomers against Oral Candida Related to Root Caries

The proportion of older people within the general population is expanding due to the decline of birth rate and the increase of life expectancy. Increasing elderly populations, which is retaining its teeth longer, leads to oral health problems, for example, root caries. The main etiological factor for the initiation and development of root caries is the appearance of cariogenic biofilm. The acid-producing and acid-tolerant bacteria and oral yeast, such as Candida albicans are the major contributors in root caries formation. A new generation of adhesives is developed with several modifications for the prevention of dental caries by incorporating antimicrobial components. The aim of this study was to investigate the antimicrobial effect of adhesive containing calcium salt of acidic monomers on the biofilm formation of oral Candida related to root caries. In the experiments, the flat-bottom surfaces of 96-well plate were painted with an adhesive containing calcium salts of 4-methacryloxyethyl trimellitic acid (CMET) and 10-methacryloyloxydecyl dihydrogen calcium phosphate (MDCP) (Bio-Coat, CA, Sun Medical, Japan). Then they were LED light-cured and coated with sterile saliva at 37 °C for 60 min. The biofilm formation was made by adding of Candida albicans (ATCC 10238 and two clinical strains) suspensions (107 colony forming unit/mL) and incubated at 37°C for 24 h. The amount of vital biofilm was determined by WST-8 Microbial Cell Counting Kit (Dojindo Molecular Technologies, USA). All experiments were done in triplicate and repeated three times. Statistical analysis was performed using Student’s t-test. The results clearly showed that adhesive could significantly inhibit biofilm formation of all tested Candida compared with a control. This suppressive effect was not different among the strains of Candida. The percentages of vital biofilm reduction were 25% to 40%. The ability of this adhesive to suppress biofilm of oral yeast may be its antimicrobial property of acidic monomer or the effect of calcium ion within the adhesive, which can alter Candida cell morphology, and influence their structures or process of biofilm formation. In conclusion, an adhesive containing calcium salts of acidic monomers could significantly inhibit biofilm formation of C. albicans. This adhesive could be effectively applied to exposed root surfaces to prevent or inhibit the progression of root caries. Further studies are necessary to clarify the effect on multispecies biofilm, on long-term activity, and in vivo conditions.

The antifungal susceptibility of Candida albicans isolated from HIV/AIDS patients

Background: Candida albicans was found to be dominant in patients with human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS). The antifungals fluconazole, ketoconazole, and nystatin were used as oral candidiasis therapy for HIV/AIDS, each of which has differing susceptibility in oral candidiasis therapy. Purpose: The present study aimed to evaluate the susceptibility and antifungal resistance to oral C. albicans in HIV/AIDS patients. Methods: The subjects followed the universal precaution principles. Oral Candida species were isolated from the saliva of 98 HIV/AIDS subjects. Identification of Candida species was carried out by the mycobiotic agar of API 20 C Aux system. Susceptibility and resistance antifungal tests on the Candida species were performed using a Fungus ATB Kit. Results: Candida albicans was the most dominant species found from 98 subjects (95%). The rest were other Candida species. There are 41 subjects (42%) with a history of oral candidiasis, and 57 subjects (58%) without. The history of those who used antifungals were: nystatin = 60 subjects (61%), fluconazole = 39 subjects (40%), and ketoconazole = two subjects (2%). These antifungals have a susceptibility above 80% against C. albicans, except the nystatin group (79%) (p>0.05; 0.628), but fluconazole has a strong correlation (r=0.820) to susceptibility, susceptibility-dependent dose, and resistance. Conclusion: Candida albicans was dominant in the saliva of HIV/AIDS patients. This fungus was effectively treated by fluconazole, ketoconazole and nystatin. These antifungals had a high susceptibility at ≤ 8 μg/mL to C. albicans.

Biomaterials for the Prevention of Oral Candidiasis Development

Thousands of microorganisms coexist within the human microbiota. However, certain conditions can predispose the organism to the overgrowth of specific pathogens that further lead to opportunistic infections. One of the most common such imbalances in the normal oral flora is the excessive growth of Candida spp, which produces oral candidiasis. In immunocompromised individuals, this fungal infection can reach the systemic level and become life-threatening. Hence, prompt and efficient treatment must be administered. Traditional antifungal agents, such as polyenes, azoles, and echinocandins, may often result in severe adverse effects, regardless of the administration form. Therefore, novel treatments have to be developed and implemented in clinical practice. In this regard, the present paper focuses on the newest therapeutic options against oral Candida infections, reviewing compounds and biomaterials with inherent antifungal properties, improved materials for dental prostheses and denture adhesives, drug delivery systems, and combined approaches towards developing the optimum treatment.

Oral Candida Predicts Streptococcus mutans Emergence in Underserved US Infants

Despite the cariogenic role of Candida suggested from recent studies, oral Candida acquisition in children at high risk for early childhood caries (ECC) and its association with cariogenic bacteria Streptococcus mutans remain unclear. Although ECC disproportionately afflicts socioeconomically disadvantaged and racial-minority children, microbiological studies focusing on the underserved group are scarce. Our prospective cohort study examined the oral colonization of Candida and S. mutans among 101 infants exclusively from a low-income and racial-minority background in the first year of life. The Cox hazard proportional model was fitted to assess factors associated with the time to event of the emergence of oral Candida and S. mutans. Oral Candida colonization started as early as 1 wk among 13% of infants, increased to 40% by 2 mo, escalated to 48% by 6 mo, and remained the same level until 12 mo. S. mutans in saliva was detected among 20% infants by 12 mo. The emergence of S. mutans by year 1 was 3.5 times higher (hazard ratio [HR], 3.5; confidence interval [CI], 1.1–11.3) in infants who had early colonization of oral Candida compared to those who were free of oral Candida ( P = 0.04) and 3 times higher (HR, 3.0; CI, 1.3–6.9) among infants whose mother had more than 3 decayed teeth ( P = 0.01), even after adjusting demographics, feeding, mother’s education, and employment status. Infants’ salivary S. mutans abundance was positively correlated with infants’ Candida albicans ( P < 0.01) and Candida krusei levels ( P < 0.05). Infants’ oral colonization of C. albicans was positively associated with mother’s oral C. albicans carriage and education ( P < 0.01) but negatively associated with mother’s employment status ( P = 0.01). Future studies are warranted to examine whether oral Candida modulates the oral bacterial community as a whole to become cariogenic during the onset and progression of ECC, which could lead to developing novel ECC predictive and preventive strategies from a fungal perspective.