FREQUENCY OF ORAL MYCOSES IN PATIENTS WITH CHRONIC CONDITIONS
DANA CRISTINA BODNAR
1, TRAIAN BODNAR
2, CORINA MARILENA CRISTACHE
3, CRISTIAN COMĂNESCU
4, ION ALEXANDRU POPOVICI
5, GABRIELA TĂNASE
6, LILIANA
BURLIBAȘA
7, CLAUDIA-CAMELIA BURCEA
81,2,3,4,5,6,8“Carol Davila” University of București, 7University of Bucureşti
Keywords: personal health history, glossitis, risk factors
Abstract: The aim of the paper is to highlight the clinical changes (mainly mycoses) in the tongue in patients with general conditions as well as the possible etiopathogenic mechanisms and the correlation between them and local and general risk factors. The method is represented by a rigorous study conducted on 500 patients of both genders between 2010 and 2013. General conditions as well as primary or associated lingual lesions were clinically detected in 221 patients. The results indicated a high rate of primary or associated glossitis as well as a significant number of other types of lingual disorders. The data of the study are presented in graphs and tables. The important conclusion of the paper is the high rate of primary or associated fungal glossitis in patients with a history of chronic disease, as well as the existence of comorbidity-related risk factors and aggravating local-regional factors. The rate of occurrence of other types of glossitis is significantly lower.
Cuvinte cheie:
antecedente personale patologice (A.P.P.), glosite, factori de risc
Rezumat: Scopul lucrării îl reprezintă evidenţierea modificărilor clinice ale limbii (şi aici ne referim cu precădere la micoze) la pacienţii cu afecţiuni generale, precum şi a mecanismelor etiopatogenice posibile şi corelarea acestora cu factorii de risc locali şi generali. Metoda de lucru a constat într-un studiu derulat între anii 2010-2013, cu program de lucru riguros, pe un număr de 500 pacienţi de ambele sexe examinaţi, 221 fiind decelaţi cu afecţiuni generale, şi la care am decelat clinic leziuni linguale unice sau asociate. Rezultatele au indicat o frecvenţă crescută de glosite unice şi glosite asociate şi un număr semnificativ de alte tipuri de afecţiuni linguale. Datele studiului au fost prezentate în grafice şi în tabele. Concluzia importantă a lucrării este frecvenţa crescută a glositelor micotice unice sau asociate la pacienţii cu boli cronice în antecedente, existenţa factorilor de risc reprezentați de comorbidităţi şi a factorilor loco-regionali agravanţi. Celelalte tipuri de glosite au fost semnificativ mai puţine numeric.
1Corresponding author: Liliana Burlibaşa, Bulevardul Mărăşeşti, Nr. 2B, Bl. A, Sc. 2, Et. 5, Ap. 17, Sect. 4, Bucureşti, România, E-mail:
[email protected], Tel: +40723 472632
Article received on 13.06.2014 and accepted for publication on 21.07.2014 ACTA MEDICA TRANSILVANICA September 2014;2(3):286-290
INTRODUCTION
Dental medicine is a medical specialty, structurally anchored in the Romanian medicine evolution, increasingly proving the gained quality of being integrated into the general health of patients.
It is well known that, today, dental medicine cannot be regarded as a specialty strictly limited to oral health and the dentist cannot be regarded as a practitioner in this field only.
The current concept and orientation of dental medicine is significantly marked by the dental practitioner concern for not only the functions of the organs affected by the oral cavity disorders but also for the discovery of the roots of the disease.
Experience and practice have shown that the dental practitioner should address the patient in a complex and comprehensive manner to have a thorough view of the clinical situation as well as of the therapeutic solution in relation to the health of the patient. Therefore, in such cases, multidisciplinary therapeutic approach and teamwork are increasingly indicated, especially when the dental practitioner competence is exceeded by the complexity of the case, appealing to the general practitioner who treats and/or look after the patient.(1)
Starting from the idea of indissoluble links between general and oral pathology, we conducted a clinical-statistical study on a group of 500 patients of different ages and both
sexes. Some of them requested specialised assistance from the Faculty of Dental Medicine in Bucharest while other patients were hospitalised for various general conditions in different medical clinics in Bucharest.
This paper presents a part of the results of the study referring to the tongue disorders in the examined patients.
METHODS
Between 2010 and 2013, we examined 500 patients.
279 of them mentioned no general condition in their personal health record (PHR), being declared clinically healthy, and 221 patients were diagnosed with general conditions of different types, being under specialised treatment. This is graphically shown in figure no. 1.
Of the 221 patients with personal health history, 92, more exactly 46 men and 46 women, accounting for 41.62%, presented single or associated lingual lesions (figure no. 2).
Patients were divided according to gender and age in 5 groups between 20 and 60+ years of age.
It is noted that the largest number of patients was represented by the age group 60+ (26 patients, 12 women and 14 men), followed by the age group 41-50 (21 patients, 13 women and 8 men). There were 15 patients in the other age groups (figure no. 3).
Figure no. 1. The number of clinically healthy patients and of those with PHR of the total of 500 examined patients
279
221
500
0 100 200 300 400 500
healthy with PHR total
Figure no. 2. Patients with PHR and lingual lesions by gender
46 46
92
0 20 40 60 80 100
women men total
Figure no. 3. Distribution of patients with lingual disorders by gender and age
5 10 15
8
7 15
13 8 21
8 7 15
12 14 26
0%
20%
40%
60%
80%
100%
women men total
20-30 31-40 41-50 51-60 60+
The examined patients suffered from conditions that affected different organs and functions as follows:
- 16 patients with liver disorders;
- 18 patients with digestive disorders;
- 17 patients with diabetes mellitus;
- 17 patients with kidney disorders;
- 18 patients with cardiovascular disorders;
- 6 patients with haematological disorders;
Situation schematically presented in figure no. 4:
Figure no. 4. Distribution of patients by condition and gender
9 7 16
12 6
18
9 8
17
6 11
17
8 10
19
2 4
6
0 20 40 60 80 100
women men total
liver digestive D. M. kidney cardiovas hematolo
The results of the statistical study performed and processed for each group, by general condition and gender, showed a slightly larger proportion of women among the patients with liver and digestive disorders as well as with diabetes mellitus, and a larger number of men among the patients with kidney, cardiovascular and haematological disorders. However, the differences in terms of gender were not highly significant. As for the age brackets considered, there were not important differences between patients. Nevertheless, the most affected age bracket was 41-50, except for cardiovascular disorders and diabetes mellitus that were more present in patients over 60.
The obtained results, in relation to each of the above- mentioned conditions, are shown in the graphs below, intended to point out their distribution by age, gender and general condition, as follows (figures no. 5,6,7,8,910):
Figure no. 5. Number of liver disorders by gender and age bracket
1 2 4
3 0
2 3
2
4 1
1
2
2
1
3
0 2 4 6 8 10 12 14 16 18
women men total
60 + 51-60 41-50 31-40 20-30
Figure no. 6. Number of digestive disorders by gender and age bracket
2 1 3
3
0
3 3
2 2 5
1
3 2
2
4
0 2 4 6 8 10 12 14 16 18 20
women men total
60 + 51-60 41-50 31-40 20-30
Figure no. 7. Number of cases of diabetes mellitus by gender and age bracket
0 1 1
0
1 1
3 0
2 3
2
4
4 4
8
0 2 4 6 8 10 12 14 16 18
women men total
60 + 51-60 41-50 31-40 20-30
Figure no. 8. Number of kidney disorders by gender and age bracket
2 2 4
0
3
3 3
3
6
2
1
3
0
1
1
0 2 4 6 8 10 12 14 16 18
women men total
60 + 51-60 41-50 31-40 20-30
Figure no. 9. Number of cardiovascular disorders by gender and age bracket
0 1 1
2 2 4
1 1
2
2 1
3
3 5
8
0 2 4 6 8 10 12 14 16 18 20
women men total
60 + 51-60 41-50 31-40 20-30
Figure no. 10. Number of haematological disorders by gender and age bracket
0
2 2
0
1 1
1
0 1
0
0
0
1
1
2
0 1 2 3 4 5 6 7
women men total
60 + 51-60 41-50 31-40 20-30
Following the clinical examination of patients, the below-mentioned tongue disorders were detected:
- single tongue disorders (table no. 1, figure no. 11 right, left):
1 – mycotic tongue, 2 – depapillated tongue, 3 – tongue ulcer, 4 – macroglossia, 5 – white tongue, 6 – pale tongue.
- associated tongue disorders (table no. 2, figure no. 12 right, left):
1 – macroglossia + mycosis, 2 - depapillated tongue + mycosis, 3 - depapillated tongue + ulceration, 4 – exfoliated tongue + mycosis, 5 – tongue ulcer + mycosis, 6 – pale tongue + mycosis, 7 – white tongue + mycosis.
In table no. 1 and figure no. 11, it is noted that the most frequent single tongue disorders were macroglossia, ulcerative lesions and mycotic glossitis, with minimal variations by gender.
In relation to the patient general condition, more cases of glossitis were in patients, especially female ones, with digestive (6 cases), cardiovascular (6 cases), liver and kidney (5 cases each) disorders. As for male patients, the lesions were predominantly found in patients with kidney disorders (7 cases).
Table no. 1. Distribution of single tongue disorders by general condition and gender
General conditions Types of
single glossitis
General conditions
Total General conditions
Total General conditions
Total
Total
Gender F B F B F B F B F B F B Mycotic
tongue
0 0 2 0 0 0 1 0 1 2 2 1 9 Depapillated
tongue
0 0 2 0 1 0 0 1 1 2 2 0 9 Tongue ulcer 1 3 0 2 0 1 0 0 0 1 1 1 10 Macroglossia 1 1 1 0 0 0 1 2 3 1 1 1 12 White tongue 3 0 0 1 0 0 0 0 0 1 0 1 6
Pale tongue 1 0 0 0 1 1 0 0 0 0 0 0 3
6 4 5 3 2 2 2 3 5 7 6 4
Total
10 8 4 5 12 10 49
Figure no. 11. Single tongue disorders distribution in relation to the general condition: left – female patients, right – male patients
0 2
0 1 1 2
0 2
1 0 1
2 1
0
0 0
0 1
1 1
0 1
3 1 3
0
0 0
0
1 0 0
1 0
0 0
6 5
2 2
5 6
0 2 4 6 8 10 12 14
A B C D E F
Total 6 5 4 3 2 1
0 0 0 0 2 1
0 0 0 1
2
3 2 1 0 0
1 1 1
0
0 2
1 1 0
1 0
0 1 0 1
0 1
0 0
0 4
3 2
3 7
4
0 2 4 6 8 10 12 14 16
A B C D E F
Total 6 5 4 3 2 1
Legend:
1 - mycotic tongue A - digestive disorders 2- depapillated tongue B – liver disorders
3 - tongue ulcer C – haematological disorders 4 – macroglossia D – diabetes mellitus 5 – white tongue E – kidney disorders 6 – pale tongue F – cardiovascular disorders
As for the frequency of the cases of glossitis with associated manifestations, as it is shown in table 2 and figure 12 (left and right), our study allowed us to highlight the large number of cases of macroglossia associated with mycosis (22 cases, accounting for 51.16% of the total of 43 associated glossitis, 13 of them in female patients) and a number of 7 cases (16.2%) in patients with diabetes mellitus and digestive disorders, and 6 cases (13.95%) in patients with cardiovascular disorders. Otherwise, the number of cases in relation to the general condition showed no significant values.
Figure no. 12. Associated tongue disorders in relation to the general disease: left – female patients, right – male patients
2 3
0 5
1 2
1 1
0 1
0 0
1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
2 0
0 0
0 0
6
4
0 7
1 2
0 2 4 6 8 10 12 14 16
A B C D E F
Total 7 6 5 4 3 2 1
1 0 0
3 2 3
0
0 0
0 2 0
0 1 1
1 0
0
0 1 1
0 0 2
0 2
0
1 0
0
0 0
0 0
0 1
1 0
0 0
0 0
1 4
2 5
4 6
0 2 4 6 8 10 12 14
A B C D E F
Total 7 6 5 4 3 2 1
Table no. 2. Distribution of complex tongue disorders in relation to the general condition and gender General conditions
Types of associated lesions Digestive Liver Haematological Diabetes mellitus
Kidney Cardio-
vascular
Total
Gender F B F B F B F B F B F B
Macroglossia+mycosis 2 1 3 0 0 0 5 3 1 2 2 3 22
Depapillated tongue + mycosis 1 0 1 0 0 0 1 0 0 2 0 0 5
Depapillated tongue + ulceration 1 0 0 1 0 1 0 1 0 0 0 0 4
Exfoliated tongue + mycosis 0 0 0 1 0 1 0 0 0 0 0 2 4
Tongue ulcer + mycosis 0 0 0 2 0 0 1 1 0 0 0 0 4
Pale tongue + mycosis 0 0 0 0 0 0 0 0 0 0 0 1 1
White tongue + mycosis 2 1 0 0 0 0 0 0 0 0 0 3
6 2 4 4 0 2 7 5 1 4 2 6
Total
8 8 2 12 5 8 43
DISCUSSIONS
The results of the presented studies regarding the interrelationships between tongue disorders and a number of risk factors, such as the diseases analysed by us in the present paper, as well as the study of the frequency of various clinical forms of glossitis in relation to the patient general condition, gender, and age highlight a number of elements that require comments and discussions.
Therefore, following the study of a batch of 221 patients that had various general conditions in their personal health record, only 92, representing 41.62% were diagnosed with single or associated forms of glossitis. The frequency of mycotic nature of glossitis was high as they were present in 49 cases, representing 53.26% of the 92 cases of glossitis. Among them, there were 9 cases (18.36%) of single mycotic glossitis and 39 cases (79.59%) of associated glossitis.
The analysis of the patients according to nosology led to data that were similar to those in previous papers related to conditions such as nephropathy and diabetes mellitus (1,2,3,4), as well as cardiovascular disorders.(5)
The results obtained following the analysis of the batch of 92 patients allowed for the presentation of the risk represented by general conditions in determining the frequency of oral lesions, with direct reference to lingual ones. Mention should be made that the value of the data should be considered in direct relation to the way the batch was established, based on clinical diagnosis criteria, therefore the frequency of glossitis occurrence may be under the real level. Regardless of the mechanism that lies at the basis of the interrelationships between the frequency of mycotic glossitis, by far the most frequent in our study, and oral conditions in general (oral biocenosis disruption, vitamin and/or enzymatic imbalance, allergies, side effects etc.), antibiotic therapy appears to be the dominant risk factor in oral mycoses.
The large number of Candidiasis glossitis appears to be directly proportional to the toxicity of antibiotics. Among them, tetracycline has the greatest number of side effects, being thus the most important cause of oral mycoses.(4) The results obtained by us are similar to those presented by other authors.(2,3,6,7,8)
As far as the clinical forms of glossitis are concerned, among the single forms (49-53.26%), macroglossia is dominant – 12 cases representing 24.48% of the total number of cases of single glossitis, followed by ulcerative lesions located on the sides of the tongue, 10 cases (20.4%), and by mycotic and depapillated tongue, 9 cases (18.36%) each. As for the cases of associated glossitis (43 – 46.73%), mycotic macroglossia was predominant – 22 cases representing 61.15% of the total number, followed by depapillated tongue associated with mycosis, 5 cases (11.62%), exfoliated or ulcerative tongue, all
associated with mycosis, 4 cases (9.30%) each, 3 cases of white tongue with mycosis (6.90%), and 1 case of pale tongue with mycosis (2.40%).
It seems reasonable to assume that the occurrence of mycotic glossitis is related to the antibiotic therapy without protection against fungi, while the other forms of glossitis may be related to the general condition that leads to the decrease in the general and local body defence capability. In this regard, an important role is played by local-regional factors such as:
irritating factors (carious lesions with sharp edges, dentures with sharp hooks, incorrect dentures), presence of large edentulous areas without dentures, poor oral hygiene etc.
The forms of glossitis detected by us in the conducted study are not specific to these cases only, as they frequently occur in other clinical situations when the patient immunity is low because of different causes.
CONCLUSIONS
The following ideas emerge from the research conducted by us:
• antibiotic therapy represents the most important risk factor responsible for the occurrence and frequency of mycotic glossitis by endogenous infection with potentially pathogenic yeasts;
• debilitating general conditions, as the ones analysed by us in the present paper, also represent important risk factors for the occurrence and frequency of tongue lesions, although they are far below the mycotic ones;
• the most frequent clinical forms of glossitis are represented by the single ones, which can be often associated with other types of glossitis;
• the lesions detected by us in the analysed general conditions are not specific forms, as they can also occur in other disorders, being in fact the consequence of the decrease in the body defence capability and the low immunity caused by the conditions in the personal health record.
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