Medical Care
Amphotericin B is an effective treatment for all forms of oral deep fungal infection. Flucytosine and rifampin enhance the activity of amphotericin B and may be indicated when the response to amphotericin B is inadequate. However, other agents that are less cytotoxic may also be effective. Treatment variably continues for 6-12 weeks after culture results are negative.
Azoles are considered better but the cost is prohibitive where they are needed most, that is, in resource-poor areas. [32, 33] Azoles such as voriconazole or posaconazole may be required in recalcitrant or invasive infections resistant to other antimycotic agents, especially in immunocompromised patients with unusual mycotic infections. [34] Statins may have some antifungal activity. [33]
Surgical Care
In addition to medical therapy, surgical debridement may be required, especially in aspergillosis and zygomycosis (mucormycosis). Zygomycosis used to be almost uniformly fatal and still has a mortality rate approaching 20%; therefore, control of underlying disease is essential if possible, together with systemic amphotericin or azole therapy (eg, fluconazole, itraconazole, or posaconazole) and surgical debridement and, as some suggest, hyperbaric oxygen. [35]
Surgery may be further indicated in cases of mycoses to correct any defects resulting from fungal destruction of the maxilla, orbit, and/or cranial base.
Consultations
Consultation with a respiratory medicine specialist or an immunologist may be helpful.
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Cryptococcosis. Left image shows solitary, destructive lesion resulting in necrosis of alveolar bone and palatal mucosa; note the superficial pseudomembranous candidiasis of the palate. Right image shows nonspecific chronic ulceration of the buccal mucosa due to cryptococcosis; this is associated with submucosal induration and regional adenopathy. Courtesy of David Sirois, DMD, PhD.
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Aspergillosis. Note deep mucosal ulceration and nodular expansion of the hard palate. Courtesy of David Sirois, DMD, PhD.
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Blastomycosis. Top image shows nonspecific papillary nodular lesion on the hard palate. Bottom image shows extensive ulceration involving the skin of the face and neck. Courtesy of David Sirois, DMD, PhD.
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Histoplasmosis. Top image shows periodontal recession and deep ulceration with exposed necrotic alveolar bone (arrow). Bottom image shows solitary, deep ulceration of the gingivae also associated with necrotic bone (arrow). Courtesy of David Sirois, DMD, PhD.
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Mucormycosis. Top left image shows multiple, deep ulcerations (arrows) of the hard palate. Top right image shows destruction of the palate and the floor of the orbit (failed skin graft of the right eye after orbital enucleation); this infection originated in the maxillary sinus. Bottom image shows similar deep, destructive ulceration of the left posterior maxillary alveolar bone and mucosa due to mucormycosis of the maxillary sinus. Courtesy of David Sirois, DMD, PhD.
