JCDA - Canadian Dental Association

Point of Care
Question 3
Candida albicans is a commensal organism found in the
oral cavity of an estimated 50% of healthy patients. Local
factors, such as reduced vertical dimension of occlusion
secondary to worn dentures, and systemic factors, including
reduced host defences secondary to immunosupression
(Fig. 1), xerostomia (Fig. 2), endocrine disorders, or use of
antibiotics or corticosteroids, can predispose a person to
candidiasis. Patients with classic signs of candidiasis can be
diagnosed clinically. However, when the clinical presentation
is ambiguous (Fig. 3) and the patient’s chief complaint
(e.g., burning of the tongue or oral mucosa) could be
caused by conditions other than candidal overgrowth, it is
appropriate to confirm or exclude the clinical impression
before initiating therapy.
Direct culture techniques are too sensitive to distinguish
cases of candidal overgrowth from commensal populations
and should be reserved for identification of candidal species
Figure 1: Widespread acute oropharyngeal
candidiasis in a patient with no obvious risk
factors. Further testing revealed that the
patient was HIV positive. Case provided by
Dr. John Fantasia.
Figure 4: Set-up for chairside exfoliative
cytology test for Candida. Required supplies
include glass slides, cytology fixative and
wooden tongue depressor.
680 November 2003, Vol. 69, No. 10
Are there any simple tests that can be employed at chairside to confirm a suspected case of
candidal overgrowth?
Figure 2: Candidiasis of the dorsal tongue.
The patient presented with medicationrelated
xerostomia and burning of the
tongue. The fungal infection resolved after a
14-day course of fluconazole. Case
provided by Dr. John Fantasia.
Figure 5: Chairside exfoliative cytology test
for Candida. The material is transferred to a
glass slide and evenly spread by a gentle
back-and-forth motion.
in immunocompromised patients who are resistant to treatment
with conventional antifungal agents.
Candidal organisms can be identified microscopically in
tissue obtained by biopsy or exfoliative cytology. In the
latter case, a potassium hydroxide preparation can be used,
which involves lysing the background epithelial cells to
allow easier visualization of candidal hyphae and spores.
This technique has several disadvantages: several steps must
be performed in the dental office, the clinician must possess
a microscope, and no permanent record is generated.
An alternative to the potassium hydroxide preparation
test is a relatively simple and accurate exfoliative cytology
test that can be performed at chairside (Fig. 4). Use a moistened
wooden tongue depressor to scrape the suspect area. If
the patient wears a removable prosthesis, sample the tissue
side of the prosthesis as well. Transfer the material to a glass
slide and spread evenly with a gentle back-and-forth
motion (Fig. 5). Immediately spray the slide with a thin
Figure 3: Acute atrophic candidiasis. The
patient presented with a chief complaint of
burning sensation of the tongue. Clinical
examination revealed diffuse loss of the
filiform papillae of the dorsum of the
tongue. On further inquiry, the patient
revealed that he had recently completed a
course of broad-spectrum antibiotics.
Figure 6: Periodic acid-Schiff staining of the
cytologic preparation. Numerous purplestaining
fungal hyphae are evident.
Epithelial cells are visible in the background.
Journal of the Canadian Dental Association