Isolation of Candida spp. from denture-related stomatitis in Pará, Brazil

Lurdete Maria Rocha Gauch Simone Soares Pedrosa Fabíola Silveira-Gomes Renata Antunes Esteves Silvia Helena Marques-da-Silva About the authors

ABSTRACT

The aim of this study was to isolate and identify Candida species from the oral cavity of denture wearers with denture-related stomatitis who were attended at the University Federal of Pará (Belém City, Pará State, Brazil). A total of 36 denture wearers with denture-related stomatitis were included, and type I (50%), type II (33%) and type III (17%) stomatitis were observed. Candida spp. were isolated from 89% of the cases and included five different Candida species. C. albicans was the most frequently recovered species (78% of the cases), followed by C. famata and C. tropicalis. We observed a significant association between Candida species isolation and unsatisfactory denture condition (p = 0.0017). Our results demonstrated the highly frequency of Candida species isolation in denture wearers with denture-related stomatitis and showed the relationship between these species and poor denture maintenance.

Keywords:
Candida albicans; Candida non-albicans; Stomatitis

Introduction

Approximately 200 Candida species are known, and 10% can cause infections in humans. C. albicans is the most frequently described species in cases of hospital infections, followed by C. parapsilosis, C. tropicalis and C. glabrata.11 Maluche ME, Santos JI. Candida spp e infecções hospitalares: aspectos epidemiológicos e laboratoriais. RBAC. 2008;40:65-67. The frequency at which these species are observed has significant implications for human infections. These species are commensal organisms that constitute part of the normal oral microbiota, and they are present in 30-60% of healthy individuals and 60-100% of patients with dentures.22 Loster BW, Loster J, Wieczorek A, Ryniewicz W. Mycological analysis of the cavity of patients using acrylic removable dentures. Gastroenterol Res Pract. 2012;:951572. The long-term use of dentures is the most important risk factor for Candida species colonization of the mucosa surface and may be sufficient for the development of oral candidiasis.33 Abaci O, Ozturk B, Boyacioglu H. Determining Candida spp. incidence in denture wearers. Mycopathologia. 2010;169:365-372. Oral candidiasis is associated with mucosal trauma caused by poor denture fit, the increasing age of the denture wearers, the increased age of the dentures, fungal infections (primarily C. albicans) and poor dental hygiene.44 Bulad K, Taylor RL, Verran J, McCord JF. Colonization and penetration of denture soft lining materials by Candida albicans. Dent Mater. 2004;20:167-175.

5 Jeganathan S, Lin CC. Denture stomatitis - a review of the etiology, diagnosis and management. Aust Dent J. 1992;37:107-114.
-66 Webb BC, Thomas CJ, Willcox MDP. Candida-associated denture stomatitis. Aetiology and management: a review. Part I. Factors influencing distribution of Candida species in the oral cavity. Aust Dent J. 1998;43:45-50. In this context, the adherence of Candida to the surface of denture materials, such as polymethyl methacrylate, facilitates colonization by Candida.77 Silva S, Henriques M, Hayes A, Oliveira R, Azeredo J, Williams DW. Candida glabrata and Candida albicans co-infection of an in vitro oral epithelium. J Oral Pathol Med. 2011;40:421-427.,88 Waters MG, Williams DW, Jagger RG, Lewis MA. Adherence of Candida albicans to experimental denture soft lining materials. J Prosthet Dent. 1997;77:306-312. The mechanisms by which C. albicans adhere to polymeric surfaces (e.g., dentures) primarily include biofilm formation and morphological switching, which facilitate the colonization of these materials by the fungus. Colonization is the main risk factor for the development of denture-related stomatitis (DRS), which is the most common clinical manifestation of Candida infection in denture wearers.99 Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont. 2011;20:251-260.

Infection by Candida spp. is frequently observed in patients with dentures and may lead to secondary oral lesions, such as lichen planus, leukoplakia and carcinoma.1010 Spolidorio LC, Martins VRG, Nogueira RD, Spolidorio DMP. Frequência de Candida spp em biópsias de lesões da mucosa oral. Pesq Odont Bras. 2003;17:89-93.Candida species colonization1111 Navas EAFA, Inocêncio AC, Dias J, et al. Oral distribution of Candida species and presence of oral lesions in Brazilian leprosy patients under multidrug therapy. J Oral Pathol Med. 2009;38:764-767.,1212 Reichart PA, Samaranayake LP, Bendick CH, Schmidt-Westhausen AM, Jayatilake JA. Prevalence of oral Candida species in leprosy patients from Cambodia and Thailand. J Oral Pathol Med. 2007;36:342-346. and infections99 Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont. 2011;20:251-260. in the oral cavity of denture wearers have been reported worldwide, and C. albicans is particularly prevalent.1313 Martins M, Henriques M, Ribeiro AP, et al. Oral Candida carriage of patients attending a dental clinic in Braga, Portugal. Rev Iberoam Micol. 2010;27:119-124. Moreover, the isolation of Candida species other than C. albicans has been increasing, which is likely because of the misuse of antifungals.1414 Snydman DR. Shifting patterns in the epidemiology of nosocomial Candida infections. Chest. 2003;123:500S-503S. In Brazil, few studies have demonstrated the profile of Candida species related to colonization of the denture surface or oral mucosa and the incidence of these lesions in denture wearers.1515 Sanitá PV, Pavarina AC, Giampaolo ET, et al. Candida spp. prevalence in well controlled type 2 diabetic patients with denture stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111:726-733. Therefore, we focused this study on the isolating and identifying Candida species from the surface of dentures and the oral mucosa of denture wearers with DRS.

Materials and methods

Ethical aspects

The study was approved by the Ethics Committee of Evandro Chagas Institute (CEP/IEC 032/10) and conducted between March and October 2012. All patients were informed about the study and provided written informed consent.

Population

Thirty-six (n = 36) patients fitted with acrylic-based dentures who presented with denture-related stomatitis were included. The patients were fitted with complete dentures (n = 32) or partially removable dentures (n = 4). All of the participants were attended at the dental school clinic at the University Federal of Pará (Belém, Pará, Brazil). Analyses were performed of the patient demographic data, which included age, gender, hygiene habits (poor or not), mouthwash use, present denture condition (satisfactory or unsatisfactory) and qualitative characteristic (new or old dentures). The presence of DRS was assessed according to a modified version of Newton's classification.1616 Newton AV. Denture sore mouth: a possible etiology. Br Dent J. 1962;112:357-360. The severity of the palatal inflammation was classified as (1) no stomatitis, which included no evidence of palatal inflammation or slight color change of the palate mucosa; (2) stomatitis type I, which included petechiae dispersed throughout all or any part of the palatal mucosa in contact with the denture; (3) type II, which included macular erythema without hyperplasia; and (4) type III, which included diffuse or generalized erythema with papillary hyperplasia.

The patient exclusion criteria included the presence of diabetes or autoimmune disease and the use of corticosteroids.

Isolation and identification

After an examination of the oral cavity, denture and mucosal specimens were harvested by scraping sterile swabs across the inner surface of the denture (basis of prosthesis, BP) and the oral mucosa (palatal mucosa, PM) in contact with the denture. Subsequently, the specimens were cultured in Sabouraud dextrose agar (Difco, Laboratories, Detroit, MI, USA), incubated at 35 °C and observed daily for 7 days. When the growth of yeast colonies was observed, the Gram stain method was used to verify the absence of bacterial contamination. The yeasts were identified via carbohydrate assimilation profiles using the Vitek 2 System (BioMerieux I'Etoile, France) according to the manufacturer's instructions.

Yeasts identified as C. dubliniensis were subjected to molecular confirmation because of the close phenotypical relationship of this species with C. albicans. Briefly, genomic DNA was extracted as previously described,1717 Sambrook J, Fritsch EF, Maniatis T. Molecular Cloning: A Laboratory Manual. 2nd ed. Cold Spring Habor Laboratory Press; 1986. and when necessary, molecular identification was performed as described by Mannarelli and Kurtzman1818 Mannarelli BM, Kurtzman CP. Rapid identification of Candida albicans and other human pathogenic yeasts by using short oligonucleotides in a PCR. J Clin Microbiol. 1998;36:1634-1641. (C. dubliniensis/forward: CDU2 - 5'-AGT TAC TCT TTC GGG GGT GGC CT-3'; C. dubliniensis/reverse: NL4CAL - 5'-AAG ATC ATT ATG CCA ACA TCC TAG GTA AA-3') and by Luo and Mitchell1919 Luo G, Mitchell TG. Rapid identification of pathogenic fungi directly from cultures by using multiplex PCR. J Clin Microbiol. 2002;40:2860-2865. (C. albicans/forward: CALB1 - 5'-TTT ATC AAC TTG TCA CAC CAG A-3'; C. albicans/reverse: CALB2 - 5'-ATC CCG CCT TAC CAC TAC CG-3'). The mix was prepared to a final volume of 25 µL as follows: 10× MgCl2 (2 µL), 10 mM dNTP (1 µL), 10× PCR buffer (2.5 µL), Q solution (2 µL), Taq DNA polymerase (1 U; Invitrogen Life Technologies, Carlsbad, Calif.) and genomic DNA template (2 µL). Amplification was performed in a thermal cycler (TX96 plus, Amplitherm, Axigen) as follows: for C. dubliniensis: 98 °C for 3 min; followed by 35 cycles of 95 °C for 1 min, 52 °C for 1.5 min, and 72 °C for 10 min; and then 72 °C for 10 min; and C. albicans: 96 °C for 5 min; followed by 40 cycles of 94 °C for 30 s, 58 °C for 30 s, and 72 °C for 30 s; and then 72 °C for 15 min. The PCR products were submitted to horizontal electrophoresis. The amplified fragments were 175 bp and 273 bp for C. dubliniensis and C. albicans, respectively.

Statistical analysis

Statistical inferences of the descriptive results were performed based on non-parametric tests, such as the G adherence independence test, using BioEstat version 5.3 (Instituto Maumirauá, Belém, Pará, Brazil). Statistical significance was considered at p ≤ 0.05.

Results

Thirty-six (n = 36) denture wearers with DRS were included in this study. The patients ranged in age from 40 to 83 years (mean age = 62 years) and included 12 males (33%) and 24 females (67%). According to Newton's classification, the DRS cases were distributed as follows: Type I (50%), Type II (33%), and Type III (17%) among the cases. Candida species were isolated from the BP only (17%), FM only (5%) and BP and FM simultaneously (67%). In four cases (11%), Candida species were not isolated. Based on biochemical or biochemical and molecular identification, we observed five different Candida species. C. albicans was the most frequently observed species (78% of the cases), and it was observed alone or in simultaneous isolations with C. famata, C. tropicalis or C. parapsilosis. The restricted isolation of Candida species other than C. albicans was observed in 11% of the cases. All of these results are summarized in Table 1.

Table 1
Presence of Candida species in the oral specimens from 36 denture wearers with denture-related stomatitis.

According to the demographics data, an unsatisfactory denture condition was an influencing factor for the isolation of Candida species (p = 0.0017); however, gender (p = 0.7015), mouthwash use (p = 0.6514), hygiene habits (p = 0.3897), continuous denture use (p = 0.4011) and old dentures (p = 0.2502) were not related to Candida species isolation.

Discussion

DRS exhibits a multifactorial etiology and is associated with denture use, indicating that disease presentation can be affected by both endogenous and exogenous factors.77 Silva S, Henriques M, Hayes A, Oliveira R, Azeredo J, Williams DW. Candida glabrata and Candida albicans co-infection of an in vitro oral epithelium. J Oral Pathol Med. 2011;40:421-427.,99 Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont. 2011;20:251-260. A critical risk factor, however, is the colonization of the oral mucosa by Candida species.2020 Zomorodian K, Haghighi NN, Rajaee N, et al. Assessment of Candida species colonization and denture-related stomatitis in complete denture wearers. Med Mycol. 2011;49:208-211. In the present study, Candida spp. were isolated in 89% of the cases of denture wearers with DRS (according to Newton's classification), thereby reinforcing the relationship between Candida spp. and DRS. In Brazilian denture wearers, DRS was previously observed as the major lesion in the oral cavity,2121 Ferreira RC, Magalhães CS, Moreira NA. Oral mucosal alterations among the institutionalized elderly in Brazil. Braz Oral Res. 2010;24:296-302. which is consistent with our results. In the present study, the factor that influenced whether Candida was isolated was an unsatisfactory denture condition. The frequent maintenance of dentures allows for improvements to certain functional characteristics, such as the RVD (rest vertical dimension) and VDO (vertical dimension of occlusion) of the patient, the adhesion of the denture to the mucosa and the diminution of the resin roughness. Improving these factors may decrease microorganism contamination of the surface denture, which will influence the oral health of denture wearers. In this context, Pereira-Cenci et al.2222 Pereira-Cenci T, Cury AA, Cenci MS, Rodrigues-Garcia RC. In vitro Candida colonization on acrylic resin and denture liners: influence of surface free energy, roughness, saliva, and adhering bacteria. Int J Prosthodont. 2007;20:308-310. and Park et al.2323 Park SE, Blissett R, Susarla SM, Weber H-P. Candida albicans adherence to surface-modified denture resin surfaces. J Prosthodont. 2008;17:365-369. observed that the colonization of dentures by Candida species is caused by surface roughness, which facilitates the adhesion of the yeast to resin dentures. Because the adherence of C. albicans to acrylic surface resins is related to the surface porosity and roughness, denture surfaces can be considered an infection source, and these findings are consistent with the significant colonization observed in denture wearers presenting with DRS because all patients were fitted with acrylic resin dentures. Moreover, the results support the relationship between unsatisfactory denture condition and Candida species isolation.

Others factors have been frequently reported as influential in the development of DRS. For example, Bulad et al.44 Bulad K, Taylor RL, Verran J, McCord JF. Colonization and penetration of denture soft lining materials by Candida albicans. Dent Mater. 2004;20:167-175. mentioned that the continuous use of dentures facilitated denture stomatitis because extended mucosal exposure to dental plaques may intensify certain injuries. Additionally, Darwazeh et al.2424 Darwazeh AMG, Hammad MM, Al-Jamaei AA. The relationship between oral hygiene and oral colonization with Candida species in healthy adult subjects. Int J Dent Hyg. 2010;8:128-133. observed a strong association between poor dental hygiene and Candida colonization and suggested that plaque accumulation on the denture surface may create an ideal environment for yeast. However, an association between poor hygiene, continuous denture use or old dentures and the isolation of Candida species was not observed in this study.

Among the colonized denture wearers in our study, C. albicans was the major isolated species, followed by C. famata and C. tropicalis, which were the most frequent non-C. albicans species. These results corroborated the findings of other studies,1111 Navas EAFA, Inocêncio AC, Dias J, et al. Oral distribution of Candida species and presence of oral lesions in Brazilian leprosy patients under multidrug therapy. J Oral Pathol Med. 2009;38:764-767.,1414 Snydman DR. Shifting patterns in the epidemiology of nosocomial Candida infections. Chest. 2003;123:500S-503S.,2121 Ferreira RC, Magalhães CS, Moreira NA. Oral mucosal alterations among the institutionalized elderly in Brazil. Braz Oral Res. 2010;24:296-302.,2525 Dagistan S, Aktas AE, Caglayan F, Ayyildiz A, Bilge M. Differential diagnosis of denture-induced stomatitis, Candida and their variations in patients using complete denture: a clinical and mycological study. Mycoses. 2008;52:266-271.

26 Ge PY, He XG, Lin T, Lu XG, Shen NY, Liu WD. First isolation of Candida dubliniensis from oral cavities of dermatological patients in Nanjing, China. Mycopathologia. 2011;172:465-471.
-2727 Kadir T, Pisiriciler R, Akyüz S, Yarat A, Emekli N, Ipbüker A. Mycological and cytological examination of oral candida carriage in diabetic patients and non-diabetic control subject: thorough analysis of local etiologic and systemic factors. J Oral Rehabil. 2002;29:452-457. including other Brazilian studies.1616 Newton AV. Denture sore mouth: a possible etiology. Br Dent J. 1962;112:357-360.,2828 Lyon JP, Moreira LM, Cardoso MAG, Saade J, Resende MA. Antifungal susceptibility profile of Candida spp. oral isolates obtained from denture wearers. Braz J Microbiol. 2008;39:668-672.

29 Menezes EA, Cavalcante MS, Farias RB, et al. Frequency and enzymatic activity of Candida albicans isolates from the buccal mucosa of children of a day-care center of the city hall of Fortaleza, Ceará, Brazil. J Bras Pathol Med Lab. 2005;41:9-13.
-3030 Pires FR, Santos EB, Bonan PR, De Almeida OP, Lopes MA. Denture stomatitis and salivary Candida in Brazilian edentulous patients. J Oral Rehabil. 2002;29:1115-1119. Additionally, Sant'Ana et al.3131 Sant'Ana PL, Milan EP, Martine R, et al. Multicenter Brazilian Study of oral Candida species isolated from Aids patients. Mem Inst Oswaldo Cruz. 2002;97:253-257. reported that the presence of two or more species in the same patient can predispose the patient to recurrent stomatitis, and double isolations were also observed in denture wearers with DRS in the present study. Moreover, C. famata was observed in the PM of denture wearers who exhibited DRS and found in association with C. albicans. These results demonstrated the potential for emergent pathogens in cases of DRS.

We observed a significant frequency of DRS in Brazilian patients colonized by Candida species, and the infection was primarily caused by C. albicans. The results indicate that in the observed patients, DRS developed along a pathway that was dependent on the unsatisfactory state of the prosthesis and the colonization of the oral cavity by Candida species.

References

  • 1
    Maluche ME, Santos JI. Candida spp e infecções hospitalares: aspectos epidemiológicos e laboratoriais. RBAC 2008;40:65-67.
  • 2
    Loster BW, Loster J, Wieczorek A, Ryniewicz W. Mycological analysis of the cavity of patients using acrylic removable dentures. Gastroenterol Res Pract 2012;:951572.
  • 3
    Abaci O, Ozturk B, Boyacioglu H. Determining Candida spp. incidence in denture wearers. Mycopathologia 2010;169:365-372.
  • 4
    Bulad K, Taylor RL, Verran J, McCord JF. Colonization and penetration of denture soft lining materials by Candida albicans Dent Mater 2004;20:167-175.
  • 5
    Jeganathan S, Lin CC. Denture stomatitis - a review of the etiology, diagnosis and management. Aust Dent J 1992;37:107-114.
  • 6
    Webb BC, Thomas CJ, Willcox MDP. Candida-associated denture stomatitis. Aetiology and management: a review. Part I. Factors influencing distribution of Candida species in the oral cavity. Aust Dent J 1998;43:45-50.
  • 7
    Silva S, Henriques M, Hayes A, Oliveira R, Azeredo J, Williams DW. Candida glabrata and Candida albicans co-infection of an in vitro oral epithelium. J Oral Pathol Med 2011;40:421-427.
  • 8
    Waters MG, Williams DW, Jagger RG, Lewis MA. Adherence of Candida albicans to experimental denture soft lining materials. J Prosthet Dent 1997;77:306-312.
  • 9
    Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont 2011;20:251-260.
  • 10
    Spolidorio LC, Martins VRG, Nogueira RD, Spolidorio DMP. Frequência de Candida spp em biópsias de lesões da mucosa oral. Pesq Odont Bras 2003;17:89-93.
  • 11
    Navas EAFA, Inocêncio AC, Dias J, et al. Oral distribution of Candida species and presence of oral lesions in Brazilian leprosy patients under multidrug therapy. J Oral Pathol Med 2009;38:764-767.
  • 12
    Reichart PA, Samaranayake LP, Bendick CH, Schmidt-Westhausen AM, Jayatilake JA. Prevalence of oral Candida species in leprosy patients from Cambodia and Thailand. J Oral Pathol Med 2007;36:342-346.
  • 13
    Martins M, Henriques M, Ribeiro AP, et al. Oral Candida carriage of patients attending a dental clinic in Braga, Portugal. Rev Iberoam Micol 2010;27:119-124.
  • 14
    Snydman DR. Shifting patterns in the epidemiology of nosocomial Candida infections. Chest 2003;123:500S-503S.
  • 15
    Sanitá PV, Pavarina AC, Giampaolo ET, et al. Candida spp. prevalence in well controlled type 2 diabetic patients with denture stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:726-733.
  • 16
    Newton AV. Denture sore mouth: a possible etiology. Br Dent J 1962;112:357-360.
  • 17
    Sambrook J, Fritsch EF, Maniatis T. Molecular Cloning: A Laboratory Manual 2nd ed. Cold Spring Habor Laboratory Press; 1986.
  • 18
    Mannarelli BM, Kurtzman CP. Rapid identification of Candida albicans and other human pathogenic yeasts by using short oligonucleotides in a PCR. J Clin Microbiol 1998;36:1634-1641.
  • 19
    Luo G, Mitchell TG. Rapid identification of pathogenic fungi directly from cultures by using multiplex PCR. J Clin Microbiol 2002;40:2860-2865.
  • 20
    Zomorodian K, Haghighi NN, Rajaee N, et al. Assessment of Candida species colonization and denture-related stomatitis in complete denture wearers. Med Mycol 2011;49:208-211.
  • 21
    Ferreira RC, Magalhães CS, Moreira NA. Oral mucosal alterations among the institutionalized elderly in Brazil. Braz Oral Res 2010;24:296-302.
  • 22
    Pereira-Cenci T, Cury AA, Cenci MS, Rodrigues-Garcia RC. In vitro Candida colonization on acrylic resin and denture liners: influence of surface free energy, roughness, saliva, and adhering bacteria. Int J Prosthodont 2007;20:308-310.
  • 23
    Park SE, Blissett R, Susarla SM, Weber H-P. Candida albicans adherence to surface-modified denture resin surfaces. J Prosthodont 2008;17:365-369.
  • 24
    Darwazeh AMG, Hammad MM, Al-Jamaei AA. The relationship between oral hygiene and oral colonization with Candida species in healthy adult subjects. Int J Dent Hyg 2010;8:128-133.
  • 25
    Dagistan S, Aktas AE, Caglayan F, Ayyildiz A, Bilge M. Differential diagnosis of denture-induced stomatitis, Candida and their variations in patients using complete denture: a clinical and mycological study. Mycoses 2008;52:266-271.
  • 26
    Ge PY, He XG, Lin T, Lu XG, Shen NY, Liu WD. First isolation of Candida dubliniensis from oral cavities of dermatological patients in Nanjing, China. Mycopathologia 2011;172:465-471.
  • 27
    Kadir T, Pisiriciler R, Akyüz S, Yarat A, Emekli N, Ipbüker A. Mycological and cytological examination of oral candida carriage in diabetic patients and non-diabetic control subject: thorough analysis of local etiologic and systemic factors. J Oral Rehabil 2002;29:452-457.
  • 28
    Lyon JP, Moreira LM, Cardoso MAG, Saade J, Resende MA. Antifungal susceptibility profile of Candida spp. oral isolates obtained from denture wearers. Braz J Microbiol 2008;39:668-672.
  • 29
    Menezes EA, Cavalcante MS, Farias RB, et al. Frequency and enzymatic activity of Candida albicans isolates from the buccal mucosa of children of a day-care center of the city hall of Fortaleza, Ceará, Brazil. J Bras Pathol Med Lab 2005;41:9-13.
  • 30
    Pires FR, Santos EB, Bonan PR, De Almeida OP, Lopes MA. Denture stomatitis and salivary Candida in Brazilian edentulous patients. J Oral Rehabil 2002;29:1115-1119.
  • 31
    Sant'Ana PL, Milan EP, Martine R, et al. Multicenter Brazilian Study of oral Candida species isolated from Aids patients. Mem Inst Oswaldo Cruz 2002;97:253-257.

Publication Dates

  • Publication in this collection
    Jan-Mar 2018

History

  • Received
    27 Nov 2013
  • Accepted
    2 May 2016
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