Oral Aspergillosis: Clinical Forms, Prognosis, and Management—A Narrative Review for the Oral Clinician

Oral cavity and maxillofacial aspergillosis can take one of four clinically different forms: primary invasive aspergillosis of the oral cavity, invasive aspergillosis of the paranasal sinuses with secondary involvement of the oral cavity, chronic granulomatous invasive fungal rhinosinusitis, and non-invasive maxillary sinus fungus ball. The basis of this narrative review was a structured search of PubMed, Scopus, Cochrane CENTRAL and ClinicalTrials.gov databases. Each of the statements will be identified according to whether it is supported by direct evidence on oral or maxillofacial conditions, or whether it is an extrapolation from invasive fungal rhinosinusitis of mixed fungal aetiology or from invasive aspergillosis occurring at other sites. Direct evidence on primary invasive oral aspergillosis is restricted to small case series from a single centre involving 12–16 patients and individual case reports. Violaceous gingival margin and spontaneous pain progressing to a necrotic ulcer should be suspicious in patients with leukaemia and neutropenia; diagnosis relies on histopathology and culture. Local control in the case series was achieved mostly via haematological remission. Pooled mortality rate of about 31% is derived from acute invasive fungal rhinosinusitis of mixed aetiology and does not apply to the disease of the mouth. Antifungal treatment strategy is based on guidelines and clinical trials of invasive aspergillosis and mucormycosis. Liposomal amphotericin B is used until the exclusion of Mucorales, and either voriconazole or isavuconazole after confirmation of Aspergillus infection, in combination with debridement whenever possible. The fungus ball is related to endodontic and other dental procedures in case–control studies and is removed endoscopically without antifungals. There are no registered clinical trials for oral or sinonasal aspergillosis.