Oral Maxillofac Surg (2008) 12:6771
DOI 10.1007/s10006-008-0106-8
ORIGINAL ARTICLE
Evaluation and treatment of oral candidiasis in HIV/AIDS
patients in Enugu, Nigeria
Chima Oji & F. Chukwuneke
Published online: 12 June 2008
# Springer-Verlag 2008
Abstract
Introduction Oral candidiasis is one of the common
diseases seen in HIV/AIDS patients. It is rare if CD4+ cell
counts are above 500 l. Outbreaks are more common as
the count drops to 100 l. It may be more difficult to treat
when CD4+ cell counts fall below 50 l.
Materials and methods A retrospective review of 112 HIV/
AIDS patients with lesions in the mouth, head, and neck
seen at the oral and maxillofacial surgery units of two
public hospitals in eastern Nigeria was carried out between
2000 and 2003. The focus was on oral candidiasis patients.
Twenty-nine of these patients, made up of 11 males and 18
females, had oral candidiasis. To compare the action of two
drugs, namely, nystatin (a topical antifungal drug) and
ketoconazole (a systemic antifungal drug), we treated 15 of
the patients with nystatin in the first 2 years and the
remaining 14 with ketoconazole in the following 2 years.
Results and discussion Amongst the 15 patients treated
with topical drugs, 7 (46.7%) had complete remission, 2
(13.3%) had partial response, 4 (26.7%) remained stationary,
and 2 (13.3%) died. Out of the 14 cases treated with systemic
drugs, 11 (78.6%) had complete remission, 2 (14.3%) had
partial response, and 1 (7.1%) died.
Keywords Oral candidiasis in HIV/AIDS . Evaluation .
Treatment . Enugu . Nigeria
C. Oji (*) : F. Chukwuneke
Oral and Maxillofacial Surgery,
University of Nigeria Teaching Hospital,
Enugu, Nigeria
e-mail: chimaoji@gmail.com
Introduction
The fungus called Candida causes oral candidiasis. A small
quantity of the fungus is present in the mouth, vagina,
digestive tract, and skin. In a healthy individual, commensal
organisms and the immune system prevent the fungus from
causing disease [14]. However, a damaged and weakened
immune system, as can be seen in patients with HIV/AIDS
disease, makes it easier for the Candida to grow, cause
severe discomfort, and increase the morbidity associated
with the HIV/AIDS condition [9, 14, 21, 27]. In these high-
risk groups, antifungal prophylaxis reduces the incidence
and severity of the infection. For example, improving oral
hygiene and maintaining mechanical cleansing by rinsing
the mouth with normal saline or home-made salt water
several times a day may be helpful [12, 18]. Nittayananta
et al. [19] reported that hyposalivation is significantly
associated with the numbers of oral Candida, and xero-
stomia is commonly associated with late-stage HIV
infection. Therefore, rinsing the mouth with normal saline
may help reduce Candida attachment and make patients
feel more comfortable with their mouth conditions. These
practical, inexpensive ways may minimize the development
of Candida infection because the first step of the infection
is adhesion of Candida to the mucosa [5]. Oral candidiasis
is usually diagnosed by appearance and symptoms [1].
However, scraping the affected site and examining the
specimen under the microscope can equally confirm the
diagnoses [27]. Further laboratory tests are usually per-
formed if the infection does not clear up after drug
treatment. Several Western studies have shown that the
diagnosis of this disease in HIV/AIDS patients can be made
on clinical findings alone [1, 4]. Defining the most effective
diagnostic and therapeutic approach to curing oral candidi-
asis in HIV/AIDS patients is especially important in
68 Oral Maxillofac Surg (2008) 12:6771

Materials and methods

We carried out a retrospective study of 112 HIV/AIDS

patients with lesions in the mouth, head, and neck. The
period of the study was from January 2000 to December
2003 and it took place in the oral and maxillofacial surgery
units of Ntasiobi Specialist Hospital and the Annunciation
Hospital, both in Enugu, Nigeria. These patients were
referred to the units by the dental surgeons, medical
practitioners, and health centers in the catchments areas of
these hospitals. Relevant information during history-taking
included patients sexual habits, sociodemographic data,
onset of symptoms, and time interval before presentation.
Each patient underwent complete physical examination. We
noted the clinical and laboratory findings and focused our
attention on the 29 oral candidiasis patients. Eleven of the
patients were males and 18 were females. The lesions
showed varieties of irregular white plaques, confluent
pseudomembrane, and friable mucosa (Figs. 1 and 2). All
the patients had the same spectrum of disease at the time of
presentation. They, therefore, qualified for the study
irrespective of age, ethnic group, sex, profession, social
class, etc. Furthermore, we could not measure the lesions
because they were friable and irregular. Visual observation
and photographs (Fig. 3), therefore, determined the degree
of remission.
In the first 2 years of the study, we treated 15 of these
patients with topical antifungal drug (nystatin) in the form
Fig. 1 Oral candidiasis in a female HIV/AIDS patient
of mycostatin mouth rinse. These patients received 5 ml of
the mouth rinse in between meals. We instructed them to

developing countries, which often have limited resources

[24].
Several therapeutic regimens have been effective in
treating oral candidiasis [13, 24, 28]. Topical antifungal
therapy was recommended as the first line of treatment for
uncomplicated oral candidiasis before the advent of the
HIV/AIDS scourge. Treatment in the early part of the
twentieth century was with gentian violet. However, a
polyene antifungal (nystatin) replaced it because of resis-
tance and side effects, such as staining the oral mucosa. We
chose ketoconazole as the systemic drug of comparison
because it is easily available in Nigeria, it is cheaper than
other systemic drugs, and it is usually well-tolerated.
The aim of this study was to evaluate 29 oral
candidiasis cases amongst 112 cases that had HIV/AIDS
symptoms in the head and orofacial regions. The study
compared the responses of oral candidiasis patients treated
with topical antifungal drug (nystatin) to those treated with
systemic antifungal drug (ketoconazole) in the oral and
maxillofacial units of two specialist hospitals in Enugu,
eastern Nigeria. Fig. 2 Oral candidiasis in a male HIV/AIDS patient
Oral Maxillofac Surg (2008) 12:6771
Fig. 3 Patient in Fig. 1 after complete remission
hold the mouth rinse in the mouth for 3 min then swill it
around the mouth and swallow it. They performed this
procedure four times daily for 2 weeks. The treatment was
continued for a few days after the clinical signs and
symptoms had disappeared in those patients who had
remission after 2 weeks of commencement of the treatment.
In the following 2 years, we treated the remaining 14
patients with nizoral (ketoconazole), an antifungal tablet,
for comparison. We administered 200 mg to each patient
daily for 2 weeks. The patients took the tablets during
meals. Because ketoconazole tablets need the acidity of the
stomach to dissolve, we administered them at least 2 h before
the patients took antacids or acid-inhibiting medication. We
measured the CD4 cell counts regularly and monitored the
liver function while the patients were taking these drugs. The
acronym CD4 stands for [c(cluster of) d(differentiation
antigen) 4] and is a glycoprotein predominantly found on
the surface of helper T cells. CD4 cell count is a critical
indicator of AIDS progression that gauges the number of
CD4 cells in 1 mm3 of blood. To process and analyze the
data that we collected, we used the chi-square test (2) for
the test of significance (Table 1).
69
We did not observe any adverse reactions. However, before
the commencement of treatment in both groups, most of the
patients complained of severe discomforts from eating and
swallowing of food. We advised them to avoid acidic, spicy, or
hot foods, cigarettes, alcohol, and sugary and carbonated
drinks while the treatment was going on. This was because
these substances promote the growth of Candida and cause
discomforts while eating [21, 27]. All the patients were
advised to maintain good oral hygiene by brushing their
teeth at least twice a day and gargling with 3% hydrogen
peroxide diluted with equal amounts of water after brushing.
Results
Out of the 29 patients that had oral candidiasis, 11 (38%)
were males and 18 (62%) were females, giving a male-to-
female ratio of 1:1.6. The age range was 1670 years with a
mean of 246.4. There were no homosexuals in this study.
However, seven of the 11 males and six of the 18 females
admitted that they had more than one sexual partner. None
of the patients used condoms. Of the 15 patients treated
with topical nystatin (mycostatin mouth rinse) within the
first 2 years, 7 (46.7%) had a complete remission (Fig. 3).
Two (13.3%) had partial remission, 4 (26.7%) remained
stationary, and 2 (13.3%) died.
In the 14 patients treated with systemic antifungal drugs
(nizoral tablets = ketoconazole), 11 (78.6%) had complete
remission, 2 (14.3%) had partial response, none was
stationary, and 1 (7.1%) died of the disease. An analysis
of these figures shows statistical significant difference (p=
0.038) among those patients with total remission in favor of
systemic treatment (Table 1).
Remission in this context means a diminution or
abatement of clinical signs and symptoms of the disease
within the period of the study. Partial remission is when at
least 50% or less than 100% of the symptoms abated.
Complete remission occurred when all the clinical signs
and symptoms disappeared. We took photographs to
document these stages of remission (Fig. 3).
In both cases treated, patients with total remission had
CD4+ between 450 and 300 l, partial remission between
300 and 150 l while those that did not respond to
treatment had their CD4+ less than 150 l. The most
Table 1 Test of significance between the two treatment methods
Methods of treatment
Remission Topical (n=15) Systemic (n=14) 2 p value
50% 2 2 0.01 0.941
100% 7 11 3.13 0.076
Total 9 13 4.27 0.038
70
common side effects were altered taste sensation and
stomach upset. However, these events were mild and in
no way affected our study.
Discussion
Candidiasis is among the most common conditions in
people with HIV/AIDS. While candidiasis is a relatively
common condition in the general population, it is often the
first signal that the HIV/AIDS disease is progressing to a
more severe stage [2, 8, 15, 20]. Oral candidiasis constitutes
a major problem in the management of HIV/AIDS patients
especially in developing countries such as Nigeria. This is
in contrast to the situation in the developed world where
highly active antiretroviral treatment (HAART) is accessible.
Greenspan et al. [11] reported a marked decrease in oral
candidiasis in women who were treated with HAART. We
agree with Bendick et al. [3] and Chidzonga [6] that
inaccessibility of the medication does exist in the develop-
ing world and that a high prevalence of oral candidiasis
among HIV/AIDS patients exists. Consequently, strategies
to treat oral candidiasis in HIV/AIDS patients in developing
countries may of necessity be quite different from those
used in the developed world [26]. Out of the 29 cases in
this study, 11 (38%) were males and 18 (62%) females,
which gives a male-to-female ratio of 1:1.6. A study carried
out in Uganda by Maurizio et al. [17] in 1999 showed that
out of 85 patients with oral candidiasis in HIV/AIDS
patients, 32 (37.6%) were males and 53 (62.4%) females,
giving a male-to-female ratio of 1:1.67. This trend seems
uniform in some African countries [7, 17]. In the developed
countries, the number of males is more than that of females
[2, 23]. This is in contrast to our findings. The risk of
developing oral candidiasis in HIV/AIDS was strongly
related to the presence of other sexually transmitted disease,
various sexual behaviors, and the number of sex partners
[21, 28]. Homosexuality and abnormal sexual acts are
taboos in the Nigerian society because they are regarded as
severe moral transgressions. It is, therefore, likely that none
of our patients admitted being homosexual. However, seven
male patients and six female patients admitted to having
more than one sexual partner. This may account for the
acquisition and transmission of HIV/AIDS and other
sexually transmitted diseases in the society.
The introduction of systemic antifungal drug therapy has
radically changed the clinical course of oral candidiasis in
HIV/AIDS patients. For the past decade, topical nystatin
therapy has been considered effective in controlling oral
candidiasis [16]. Fluconazole (diflucan) is another prescrip-
tion medication that can be used as an alternative to
nystatin. It has the benefit of once a day dosing, but it is
more expensive than nystatin and ketoconazole. In a study
Oral Maxillofac Surg (2008) 12:6771
that compared fluconazole and nystatin, fluconazole was
found to be superior to nystatin [10] In another published
study by Pons et al. [25] that compared the efficacy of
nystatin and oral fluconazole in HIV-positive patients, the
clinical cure rate of nystatin was 52% and that of systemic
fluconazole 87%. In tropical countries, the efficacy of
nystatin in treating this disease is not well-known, although
a study in Zaire reported a cure rate of less than 10% [20].
In a similar study in Uganda, 10 (27%) out of 37 patients
treated with topical therapy had complete remission. In the
same study, 38 (95%) of the 40 patients treated with
systemic antifungal therapy had complete remission [17]. In
our study, 7 (46.7%) out of 15 patients treated with topical
antifungal drug (nystatin) had complete remission while 11
(78.6%) of the 14 patients treated with systemic antifungal
drug (ketoconazole) had complete remission. For this group,
potassium hydroxide preparations and culture of mucosal
scrapings gave no evidence of candidiasis. This study is in
line with the findings of other authors [16, 17, 22].
For the treatment of oral candidiasis in HIV/AIDS
patients, we conclude from our result that the use of
systemic antifungal drug (ketoconazole) was more effective
than topical antifungal drugs (nystatin). Furthermore, our
study showed that women are more affected by the disease
in this region of the world. Finally, we share the opinion of
Blignaut et al. [5] that the optimal goal in dealing with oral
candidiasis in developing countries is to prevent the
occurrence of the lesion by educating patients on how to
enhance their immunity, reduce predisposing factors that
lead to further immune impairment, and perform self-
assessment for the presence and control of the lesion.
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