ELGAMAL HATEM - 5th Course – Group: 6610ca

Topic No.11
Fungal lesions of the oral mucosa in children. Etiology, pathogenesis,
clinics, diagnostics.

The Candida fungi are the one-celled round or oval microorganisms, 2-5 mm in
size. They have no mycelium and reproduce by gemmation. The fungal cells may
organize into the chain, to produce in this way the pseudomycelium. These cells
are facultative anaerobes.

The Candida fungi are widely distributed in the environment, they often inhibit
the oral cavity. The organisms which most frequently cause pathological changes
are Candida albicans, Candida tropicalis, Candida pseudotropicalis, Candida
kefyr (crusei), Candida guilliermondi. They may form associations. The most
frequently diagnosed and virulent is Candida albicans.
If the body’s resistance decreases, in weak children the fungi attain the
pathogenic properties and cause candidosis. It often develops in children as a
secondary disease after other chronic diseases. The disease may appear in the
newborns as a primary infection, if the child has a transitory immunodeficiency.
The AIDS and oral cavity candidosis may be a clinical symptom at the
visceral and disseminated forms of candidosis, in patients with blood diseases, at
radiation lesions, hormonal dysfunctions, severe traumas and burns.
Classification of the oral cavity candidosis
 According to the clinical development: acute, chronic, relapsing,
persistent.
 According to the severity of the development: mild, moderate,
severe.
 According to the layer of the affected tissues: deep, superficial.
 According to the clinical manifestations : pseudomembranous,
atrophic, bullous, erosive, ulcerative, granulematous, hyperplastic.
 According to the cause of the disease: primary, secondary.
 According to its localization: stomatitis, glossitis, cheilitis, gingivitis.
The oral cavity candidosis may be clinically manifested as a cheilitis,
candidosis of the mouth corners ( like in angular cheilitis), glossitis, stomatitis,
gingivitis, and it may develop as an acute or chronic disease.
According to the expressed clinical symptoms the process may be a
superficial one or a deep, localized or diffuse.
 The acute pseudomambranous form of candidosis in children is
characterized by hyperemia, swelling of the mucosa, white or yellowish plaque
and it have mild, moderate or a severe development.
In the mild disease development white droplet plaque appears first on the
areas of the hyperimated mucosa (the tongue, cheeks or lips). Then some of these
formations may merge into the creamy membranes. The drops and membranes
are easily detached. After they are detached, the hyperimated desquamated
membrane is observed.
The moderate disease development is characterized by the membranous
plaque on the tongue’s back or tip, mucosa of the cheeks and lips. The plaque is
not always easily detached. After the membranous plaque is removed, we may
observe the erosion surface which may sometimes bleed, the mucosa is
hyperimated, swollen.
In the severe development of the acute candidous stomatitis we may observe
diffuse lesions of the oral mucosa with hard and soft palate affected as well as the
tonsillar pillars and posterior pharyngeal wall. But the highest concentration of
the grey plaque with underlying tissue infiltration is observed on the back of the
tongue, on the cheeks or lower lip. The angular cheilitis develops in the mouth
corners.
The patients complain about dryness of the oral cavity, the saliva is foamy.
The lymphadenitis of the submandibular lymphatic nodes may be observed. If
you try to remove the plaque, superficial layers are easily detached, if they didn’t
adhere closely to the underlying layers.
The acute atrophic form may develop after the acute pseudomembranous
form or as an independent disease. It may appear as a complication of antibiotic
therapy, or as a consequence of administration of local: inhalation, peroral
systemic corticosteroids. The affected areas are represented as hyperimated spots
with smooth surface. If the back of the tongue is affected, the mucosa becomes
dark-red, smooth, shining, the papillae smooth out. The acute atrophic form is
accompanied with severe pain, burning sensation and dryness in the oral cavity.
The chronic pseudomembranous form is observed in somatically
immunologically weak children after the development of the primary and
secondary immunodeficiency. They have continuous persistent development and
they express resistance to therapy.
The patients complain about painful sensations during the meals, when they
open their mouths, halitosis. The clinical peculiarities are lesions of all oral areas,
crumb-like plaque on the tongue’s back, it may be yellow and dark-brown. If you
try to remove the plaque, erosive surface is exposed, it may bleed. The objective
examination may diagnose the catarrhal gingivitis on the gingival mucosa, it may
develop various degrees of severity. The hard dental tissues may contain lots of
soft plaque. It may affect not only the oral mucosa, but mucous membranes of
some other organs (mucosides). The chronic pseudomembranous form may
combine with angular cheilitis or dermal fungal infections.
The chronic atrophic form is rarely observed in weak children with
orthodontic appliances. It is characterized by poor symptom combination, the
chronic enanthema and swelling of those mucosal areas which contact with the
orthodontic or orthopedic appliance may develop.
The chronic granulematous and hyperplastic forms are infrequently
observed in children.
The erosive-ulcerative, or locally invasive oral candidosis is rarely observed.
The candidosis of the mouth angles (angular stomatitis, candidous cheilitis,
candidous cheilitis), may provide for the development of any of the recalled
candidosis forms, or it may develop as an independent disease. The chronic
mycotic cheilitis is observed in the children of pre-school and school age, lip
architechtonics is impaired but the general condition of the lips isn’t changed.
The deep fissures with protruding margins are observed in the mouth
corners. The skin in these areas is slightly hyperimated, infiltrated, we may
observe skin maceration there. If a patient opens his mouth, he feels pain and
there may be bleeding.
The diagnostics of the oral mucosal candidosis relies on the patient’s
complaints, objective examination data and laboratory examination data.

Examination of a patient
- General
 analysis of feces to determine
 intestinal dysbacteriosis;
 general blood analysis
- Special
 microscopy of the scrape.
 mycologic examination.
 general urine analysis.
 serologic reaction.
 histiopathic examination.
 -allergic analyses.
 The microscopic examination of the scrape taken from the affected area
should be performed a few times to estimate the degree of spread of the
organisms.
The mycological examination provides for establishing of the results of
fungal inoculation, determination of their genus and species as well as the
resistance to the anti-fungal medications.

Medication Administration method Mechanism of

action
1. Polyene antimycotics
Pimaphycine 2,5% drops, ointment, suspension. It binds with
Applications applied 4-6 times a day during ergosterine of
10-15min. the cellular
Levorine Water suspension 20 000 units/ml, membrane,
which is prepared extemporally from the increases the
suspension powder. Tablets 500 000 units, membrane
1 tablet for sucking, 5-6 times a day for 10- permeability,
14 days and this
destroys the
fungal cell.

Nistatyne Suspension 100 000 units/ml.

Applications of 4-5 ml of suspension, 4-5
times a day. Tablets 500 000 units, 1 tablet
5-6 times a day for 10-14 days.
Amphoglucamine Suspension 100 000 units/ml.
Applications of 1 ml of suspension onto the
oral mucosa 3-4 times a day. Tablets
100 000 units; 2 tablets twice a day for 10-
14 days
2. Azols
Clotrimazol 1% solution “Candid”, 1% solution of Decrease
“Canesten”; 1 ml of suspension 3-4 times a ergosterol
day. synthesis.
Fucis 1% solution (1 tablet for 5ml of water), Cause
parenterally - 3-6 mg/kg irreversible
Fluconasol 200 mg for 5 ml of water to prepare a damage of the
(Diflucan) suspension once or twice a day fungal cells.
Capsules, 50 mg, 3-4 times a day
 If we detect from 10 to 100 colonies of the Candida fungi, it doesn’t evidence
about candidosis, but shows about possibility of the pathological condition and it
requires the further clinical examination. A person is considered to be a disease
carrier if from 100 to 1000 colonies of the formative units are detected in a
tampon. The candidosis is diagnosed if more than 1000 colonies of formative
units are detected in a tampon.
The diagnostic value of the skin tests isn’t highly estimated nowadays as
they may appear to be positive in healthy people with saprophytic yeast fungi.
And vice versa, the serologic examination has considerable importance if the
antifungal antibodies’ content increases.

The main dynamic factor is increased content at low concentrations. The

treatment of the oral cavity candidosis is performed according to the clinical
form of the disease, its severity, age of the child and general somatic condition of
the body. It includes local and general therapy.

The etiotropic therapy is aimed to affect the causative microorganism and

decrease its pathogenic properties. In a mild disease development the etiotropic
treatment may include just the local measures. In a moderate and severe
development as well as in chronic forms the etiotropic medications of local and
general action are used.

The medications used to irrigate the oral cavity are: 0,5-1% of sodium
hydrocarbonate solution, 10-20% sodium tetraborate solution in glycerine
(borax), potassium permanganate solution (1:5000), 0,025% chlorhexidine
solution, 0,01-0,1% solution of sangvirytryn, Stomatydyn, Givalex, etc.

If the positive dynamical picture of the disease development and treatment

is absent, the etiotropic antifungal medications are administered both locally and
parenterally, after the treatment was agreed with the pediatrician. The etiotropic
therapy is performed after the fungal sensitivity to antifungal medications has
been determined. The medication dosages depend on the child’s age and the
disease severity.
Antimycotics:
The complex scheme of the candidosis treatment also includes vitamin B
(thiamine, riboflavin, calcium pantothenate, pyridoxine) and ferric medications
(ferroplex, konferon, etc), medical yeasts (enterol - 250).
 Due to high immunodependence of the chronic Candida infections, it is
necessary to consult with a pediatrician about immunomodulators to be
prescribed.
If the intestinal dysbacteriosis is detected, especially after a patient has been
administered antibiotics, bacterial eubiotics are prescribed: lactobacterin,
polybacterin, bifidobacterin, bifikol, linex, etc.
It is recommended that the patients keep to a diet with vitamins and
microelements and restrict carbohydrate consumption.

To treat the acute pseudomembranous candidosis of the oral mucosa in the

newborns we should treat the oral cavity correctly. The lesions must be
processed with a 10-20% solution of a sodium tetraborate in a glycerine ( borax)
or 0,5-1 % solution of sodium hydrocarbonate.

The procedure is performed as follows: the medical solution fills the rubber
syringe, the mother holds the newborn horizontally, his head bent above the tray,
the doctor introduces the rubber syringe with a solution into the distal
department of an oral cavity between the alveolar process and a cheek.

The oral cavity of the child is easily washed, without extra pressure.
To treat the moderate and severe candidous stomatitis we may use the nistatine
suspension 3-4 times a day ( 1 tablet – 500 units dissolved in 5 ml of mother’s
mild), during 10 days, natamycine in drops, 0,5-1 ml a day for 5-7 days.
To prevent candidosis of the oral mucosa in infants both mother and child
should keep to the hygienic rules.