Identification of Candida species in the oral cavity of diabetic patients


1 Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Medical Mycology and Parasitology, Isfahan University of Medical Sciences, Isfahan, Iran

3 Department of Cellular and Molecular Biology, Isfahan Province Health Center, Isfahan, Iran


Background and Purpose: Diabetic patients are more susceptible to oral candidiasis infection than non-diabetics due to the factors promoting oral carriage of Candida. Several factors can increase colonization of Candida species in the oral cavity such as xerostomia, which reduces the salivary flow and is a salivary pH disorder. In the current study, we aimed to identify and compare the colonization level of Candida spp. in the oral cavity of diabetic and non-diabetic groups.
Materials and Methods: Swabs were taken from the mouth of 106 participants and were cultured on Sabouraud dextrose agar (SDA) medium. Likewise, the saliva samples were collected for salivary glucose and pH measurements. The study was performed during June 2014-September 2015 on two groups of diabetic patients (n=58) and non-diabetics (n=48) as the control group. The Candida spp. were identified with PCR-restriction fragment length polymorphism (RFLP) using the restriction enzymes HinfI and MspI and were differentiated by culture on CHROMagar Candida medium.
Results:The frequency of Candida spp. was higher in diabetic patients compared to non-diabetics. The most frequent Candida spp. in the diabetic patients were Candida albicans (36.2%), C. krusei (10.4%), C. glabrata (5.1%), and C. tropcalis (3.4%). Likewise, C. albicans was the most frequent species (27%) in the non-diabetic individuals. In this study, the results of both methods for identification of the isolates were consistent with each other.
Conclusion: Xerostomia and disturbance of physiological factors including pH and glucose can promote overgrowth of Candida flora in the oral cavity. These factors are considered important predisposing factors for oral candidiasis in diabetic patients. In the present study, it was observed that application of CHROMagar Candida and PCR-RFLP methods at the same time contributes to more accurate identification of isolates.


1. Garnacho-Montero J, Amaya-Villar R, Ortiz-Leyba C, León C, Álvarez-Lerma F, Nolla-Salas J, et al. Isolation of Aspergillus spp. from the respiratory tract in critically ill patients: risk factors, clinical presentation and outcome. Crit Care. 2005; 9(3):R191-9.
2. Cannon RD, Holmes AR, Mason AB, Monk BC. Oral Candida: clearance, colonization, or candidiasis? J Dent Res. 1995; 74(5):1152-61.
3. Hopcraft MS, Tan C. Xerostomia: an update for clinicians. Aust Dent J. 2010; 55(3):238-44.
4. Guggenheimer J, Moore PA. Xerostomia: etiology, recognition and treatment. J Am Dent Assoc. 2003; 134(1):61-9.
5. Akpan A, Morgan R. Oral candidiasis. Postgrad Med J. 2002; 78(922):4559.
6. Ship JA. Diabetes and oral health: an overview. J Am Dent Assoc. 2003; 134:4S-10.
7. Samaranayake LP, MacFarlane TW. Host factors and oral candidosis. Oral Candid. 1990; 66:103.
8. Vijan S. In the clinic: Type 2 diabetes. Ann Intern Med. 2010; 152(5):ITC3
9. Zegarelli DJ. Fungal infections of the oral cavity. Otolaryngol Clin North Am. 1993; 26(6):1069-89.
10. Kadir T, Pisiriciler R, Akyüz S, Yarat A, Emekli N, Ipbüker A. Mycological and cytological examination of oral candidal carriage in diabetic patients and non-diabetic control subjects: thorough analysis of local aetiologic and systemic factors. J Oral Rehabil. 2002; 29(5):452-7.
11. Budtz-Jörgensen E. Etiology, pathogenesis, therapy, and prophylaxis of oral yeast infections. Acta Odontol Scand. 1990; 48(1):61-9.
12. Rotrosen D, Calderone RA, Edwards JE Jr. Adherence of Candida species to host tissues and plastic surfaces. Rev Infect Dis. 1986; 8(1):73-85.
13. Aly FZ, Blackwell CC, Mackenzie DA, Weir DM, Clarke BF. Factors influencing oral carriage of yeasts among individuals with diabetes mellitus. Epidemiol Infect. 1992; 109(03):507-18.
14. Samaranayake LP, MacFarlane TW. The adhesion of the yeast Candida albicans to epithelial cells of human origin in vitro. Arch Oral Biol. 1981; 26(10):815-20.
15. Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. J Am Dent Assoc. 2003; 134:24S-33.
16. Jabra-Rizk MA, Brenner TM, Romagnoli M, Baqui AA, Merz WG, Falkler WA Jr, et al. Evaluation of a reformulated CHROMagar Candida. J Clin Microbiol. 2001; 39(5):2015-6.
17. Nadeem SG, Hakim ST, Kazmi SU. Use of CHROMagar Candida for the presumptive identification of Candida species directly from clinical specimens in resource-limited settings. Libyan J Med. 2010; 5(1):2144.
18. Mousavi SA, Khalesi E, Bonjar GS, Aghighi S, Sharifi F, Aram F. Rapid molecular diagnosis for-Candida species using PCR-RFLP. Biotechnology. 2007; 6(4):583-7.
19. Kanbe T, Kurimoto K, Hattori H, Iwata T, Kikuchi A. Rapid identification of Candida albicans and its related species Candida stellatoidea and Candida dubliniensis by a single PCR amplification using primers specific for the repetitive sequence (RPS) of Candida albicans. J Dermatol Sci. 2005; 40(1):43-50.
20. Beighton D, Ludford R, Clark DT, Brailsford SR, Pankhurst CL, Tinsley GF, et al. Use of CHROMagar Candida medium for isolation of yeasts from dental samples. J Clin Microbiol. 1995; 33(11):3025-7.
21. Glee PM, Russell PJ, Welsch JA, Pratt JC, Cutler JE. Methods for DNA extraction from Candida albicans. Anal Biochem. 1987; 164(1):207-13.
22. Löffler J, Hebart H, Schumacher U, Reitze H, Einsele H. Comparison of different methods for extraction of DNA of fungal pathogens from cultures and blood. J Clin Microbiol. 1997; 35(12):3311-2.
23. Metwally L, Fairley DJ, Coyle PV, Hay RJ, Hedderwick S, McCloskey B, et al. Improving molecular detection of Candida DNA in whole blood: comparison of seven fungal DNA extraction protocols using real-time PCR. J Med Microbiol. 2008; 57(3):296-303.
24. Zahir RA, Himratul-Aznita WH. Distribution of Candida in the oral cavity and its differentiation based on the internally transcribed spacer (ITS) regions of rDNA. Yeast. 2013; 30(1):13-23.
25. Fisher BM, Lamey PJ, Samaranayake LP, MacFarlane TW, Frier BM. Carriage of Candida species in the oral cavity in diabetic patients: relationship to glycaemic control. J Oral Pathol. 1987; 16(5):282-4.
26. Guggenheimer J, Moore PA, Rossie K, Myers D, Mongelluzzo MB, Block HM, et al. Insulin-dependent diabetes mellitus and oral soft tissue pathologies. II. Prevalence and characteristics of Candida and candidal lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2000; 89(5):570-6.
27. Lalla RV, D’Ambrosio JA. Dental management considerations for the patient with diabetes mellitus. J Am Dental Assoc. 2001; 132(10):1425-32.
28. Darwazeh AM, MacFarlane TW, McCuish A, Lamey PJ. Mixed salivary glucose levels and candidal carriage in patients with diabetes mellitus. J Oral Pathol Med. 1991; 20(6):280-3.
29. Haddadi P, Zareifar S, Badiee P, Alborzi A, Mokhtari M, Zomorodian K, et al. Yeast colonization and drug susceptibility pattern in the pediatric patients with neutropenia. Jundishapur J Microbiol. 2014; 7(9):e11858.
30. Shokohi T, Bandalizadeh Z, Hedayati MT, Mayahi S. In vitro antifungal susceptibility of Candida species isolated from oropharyngeal lesions of patients with cancer to some antifungal agents. Jundishapur J Microbiol. 2011; 4(2):S19-26.
31. Maheronnaghsh M, Tolouei S, Dehghan P, Chadeganipour M, Yazdi M. Identification of Candida species in patients with oral lesion undergoing chemotherapy along with minimum inhibitory concentration to fluconazole. Adv Biomed Res. 2016; 5(1):132.
32. Badiee P, Badali H, Diba K, Ghadimi Moghadam A, Hosseininasab A, Jafarian H, et al. Susceptibility pattern of Candida albicans isolated from Iranian patients to antifungal agents. Curr Med Mycol. 2016;
33. Samaranayake L, Hughes A, MacFarlane T. The proteolytic potential of Candida albicans in human saliva supplemented with glucose. J Med Microbiol. 1984; 17(1):13-22.
34. Odds FC, Evans EG, Taylor MA, Wales JK. Prevalence of pathogenic yeasts and humoral antibodies to Candida in diabetic patients. J Clin Pathol. 1978; 31(9):840-4.
35. Knight L, Fletcher J. Growth of Candida albicans in saliva: stimulation by glucose associated with antibiotics, corticosteroids, and diabetes mellitus. J Infect Dis. 1971; 123(4):371-7.
36. Belazi M, Velegraki A, Fleva A, Gidarakou I, Papanaum L, Baka D, et al. Candidal overgrowth in diabetic patients: potential predisposing factors. Mycoses. 2005; 48(3):192-6.
37. Willis AM, Coulter WA, Fulton CR, Hayes JR, Bell PM, Lamey PJ. Oral candidal carriage and infection in insulin-treated diabetic patients. Diabet Med. 1999; 16(8):675-9.
38. Dorocka-Bobkowska B, Budtz-Jörgensen E, Włoch S. Non-insulin-dependent diabetes mellitus as a risk factor for denture stomatitis. J Oral Pathol Med. 1996; 25(8):411-5.
39. Javed F, Klingspor L, Sundin U, Altamash M, Klinge B, Engström PE. Periodontal conditions, oral Candida albicans and salivary proteins in type 2 diabetic subjects with emphasis on gender. BMC Oral Health. 2009; 9(1):12.
40. Eslami H, Fakhrzadeh V, Pakdel F, Pouralibaba F, Falsafi P, Kahnamouii SS. Comparative evaluation of salivary pH levels in type II diabetic patients and healthy. J Akademik. 2011; 14:10
41. Kaminishi H, Hagihara Y, Hayashi S, Cho T. Isolation and characteristics of collagenolytic enzyme produced by Candida albicans. Infect Immun. 1986; 53(2):312-6.
42. Krcmery V, Barnes AJ. Non-albicans Candida spp. causing fungaemia: pathogenicity and antifungal
resistance. J Hosp Infect. 2002; 50(4):243-60.
43. de Paula SB, Bartelli TF, Di Raimo V, Santos JP, Morey AT, Bosini MA, et al. Effect of eugenol on cell surface hydrophobicity, adhesion, and biofilm of Candida tropicalis and Candida dubliniensis isolated from oral cavity of HIV-infected patients. Evid Based Complement Alternat Med. 2014; 2014:505204.
44. Deorukhkar SC, Saini S, Mathew S. Non-albicans Candida infection: an emerging threat. Interdiscip Perspect Infect Dis. 2014; 2014:615958.
45. Badiee P, Alborzi A, Davarpanah MA, Shakiba E. Distributions and antifungal susceptibility of Candida species from mucosal sites in HIV positive patients. Arch Iran Med. 2010; 13(4):282-7.
46. Gutierrez J, Morales P, Gonzalez MA, Quindos G. Candida dubliniensis, a new fungal pathogen. J Basic Microbiol. 2002; 42(3):207-27.
47. Deorukhkar SC, Saini S. Laboratory approach for diagnosis of candidiasis through ages. Int J Curr Microbiol Appl Sci. 2014; 3(1):206-18.
48. Shokohi T, Hashemi Soteh MB, Saltanat Pouri Z, Hedayati MT, Mayahi S. Identification of Candida species using PCR-RFLP in cancer patients in Iran. Indian J Med Microbiol. 2010; 28(2):147-51.
49. Pakshir K, Zakaei A, Motamedi M, Rahimi Ghiasi M, Karamitalab M. Molecular identification and in-vitro antifungal susceptibility testing of Candida species isolated from patients with onychomycosis. Curr Med Mycol. 2015; 1(4):26-32.
50. Melton JJ, Redding SW, Kirkpatrick WR, Reasner CA, Ocampo GL, Venkatesh A, et al. Recovery of Candida dubliniensis and other Candida species from the oral cavity of subjects with periodontitis who had well-controlled and poorly controlled type 2 diabetes: a pilot study. Spec Care Dentist. 2010; 30(6):230-4.
51. Pinto PM, Resende MA, Koga-Ito CY, Ferreira JA, Tendler M. rDNA-RFLP identification of Candida species in immunocompromised and seriously diseased patients. Can J Microbiol. 2004; 50(7):514-20.
Volume 2, Issue 2
June 2016
Pages 1-7
  • Receive Date: 09 July 2019
  • Revise Date: 06 October 2020
  • Accept Date: 09 July 2019
  • First Publish Date: 09 July 2019