Manifestations of acute forms of oral mucosa (OM) candidiasis are diverse and can have a course of drug-induced, aphthous, ulcerative and other stomatitis. Symptoms depend on the localization, course and prevalence of the pathological process [1,2, 4, 18]. Among the clinical forms of oral candidiasis, which have an acute course, there are: acute pseudomembranous candidiasis and acute erythematous (atrophic) candidiasis [5, 6, 16, 18].
Acute pseudomembranous candidiasis
Acute pseudomembranous candidiasis is more common in weakened infants and adolescents, weakened elderly people and is common in patients: with cancer - up to 60%, AIDS - more than 90% of cases [13,17].
This form of the disease is characterized by:
- complaints of heartburn and pain in the oral cavity when eating and talking, the presence of plaque on the oral mucosa. Infants refuse to eat, are tearful, body temperature is often subfebrile, sometimes febrile;
- clinically - pale skin, salivation. Against the background of diffuse hyperemia of various areas of the oral mucosa (palate, dorsum of the tongue), grayish-white cheesy plaque (exfoliated epithelium and fungal culture) is noted;
- plaque at the beginning of the disease is easily removed with a cotton swab or dental instrument, while a focus of hyperemia remains in their place. However, after some time (2-3 hours), as a result of the growth of yeast mycelium on the surface and deep into the oral cavity, a new plaque appears on this area. With the development of a severe course of candidiasis on the tongue, the friable plaque is removed with some difficulty and partially, and erythema and bleeding erosions appear on the oral cavity. This is due to the peculiarities of the structure of the tongue, the presence of folds on its dorsal surface [5,6,8,18].
Acute pseudomembranous candidiasis should be differentiated from lichen planus, soft leukoplakia and Fordyce granules, aphthous stomatitis, staphylococcal stomatitis, CO acid and alkali burns, and drug-induced allergic stomatitis [5, 6, 15]. Thus, lichen planus with oral manifestations is characterized by the presence of whitish papules. However, the papules are caused by epithelial hyperkeratosis and are not removed by scraping [3].
In mild leukoplakia, the whitish color and brittle appearance of the OM are due to parakeratosis, so it is not removed by scraping. The results of bacterioscopic examination for Candida are negative.
Fordyce granules (Fordyce glands) - are the result of heterotopia of the sebaceous glands. Typical localization on the OM of the cheeks (in the retromolar area, the line of teeth closing), lips (corners of the mouth). Fordyce glands have the appearance of yellowish granules up to 1 mm in diameter, which protrude at the level of the OM, outwardly they look like semolina scattered under the OM. The granules can merge and form whitish-yellow spots or plaques, which do not change when scraped. Candida is not detected bacteriologically.
Recurrent aphthous stomatitis (RAS) is the most common oral disease characterized by inflammatory lesions of the mobile oral mucosa with recurrent occurrence of single or multiple painful ulcers (aphthae) with a well-defined erythematous border and a yellowish-gray pseudomembranous center, and a nonspecific histological picture. The signs and symptoms of RAS are variable; the first symptom is a burning sensation that lasts from 2 to 48 hours before ulcers appear. The clinical manifestations of RAS depend on the depth of the lesion, the number in a single episode, the location, and the duration. According to these features, aphthae are divided into three main categories: small, large, and herpetiform recurrent aphthous ulcers[11,19].
Significant ulcers - deep, usually single, with a diameter of more than 1 cm (from 1 to 3 cm), affecting mainly the soft palate and tonsils; healing occurs after 2-6 weeks with scarring and deformation of the oral cavity. Minor ulcers - up to 3-5 aphthae of a round or oval shape appear on the oral cavity of the cheeks and lips, usually less than 1 cm in diameter (from 3 to 10 mm), with a fibrinous plaque of grayish-white color. The plaque is closely attached to the underlying epithelial layer, is removed after treating the affected area with a solution of proteolytic enzymes (trypsin, chemotrypsin). After removing the plaque, an erosive surface is revealed, which bleeds and is painful to the touch. Healing occurs after 7-14 days without scarring.
Herpetiform aphthous lesions are the most common aphthous manifestations, which appear multiple, superficial, and small (1–3 mm in diameter), some of which coalesce into large erosions that clinically resemble herpetic ulcers. Studies have shown that RAS is a multifactorial disease mediated by T cells and has an immunodeficiency pattern. Factors that modify the immunological responses in RAS include genetic predisposition, viral and bacterial infections, food allergies, vitamin and micronutrient deficiencies, systemic diseases, hormonal imbalances, mechanical trauma, and stress [11].
Staphylococcal stomatitis is characterized by a white, friable plaque, which is localized on a more pronounced hyperemia of the oral cavity and is easily removed with a cotton swab. In addition to oral cavity, a pustular rash and yellowish drying crusts are often found on the skin of the face, mainly on the chin. Staphylococci dominate in the pathological material taken from the lesion. Regional lymph nodes are enlarged, painful on palpation.
Allergic stomatitis manifests itself as an allergic reaction upon local contact with dental and prosthetic materials, medications – removable dentures, ointments, gels, local anesthetics, filling materials, toothpastes, etc. Among the complaints, heartburn and itching of a certain area of the oral cavity dominate.
Unlike candidal stomatitis, drug-induced allergic stomatitis occurs and develops acutely within a few minutes or hours after taking medications. It is objectively characterized by the presence of erythematous spots, and often blisters and their secondary elements, erosions, as well as the detection of allergic antibodies in the blood serum, and in the lesion area - the absence of fungal flora. Regional lymph nodes are enlarged, mobile, painful on palpation.
Burns of the OM with high-concentration acids or alkalis are more common in adults and are usually characterized by a history of accidental use for various purposes. Burns occur acutely, accompanied by burning pain with subsequent formation of a zone of coagulation or colliquation necrosis.
Acute "erythematous" atrophic candidiasis
Atrophic glossitis (AG) is characterized by the partial or complete absence of filiform and mushroom-shaped papillae on the dorsal surface of the tongue. Among the etiological factors of AG can be protein-calorie deficiency, xerostomia, diabetes mellitus, candidiasis.
Acute erythematous candidiasis has historically been called "antibiotic mouth ulcer" because it often occurs as a consequence of a decrease in the level of bacterial microflora of the oral cavity after the use of broad-spectrum antibiotics, which contributes to the overgrowth of Candida. Discontinuation of antibiotic therapy restores the normal homeostatic balance of the microbial flora, which subsequently resolves the infection without the need for therapeutic intervention. This form of the disease manifests as painful, reddened lesions throughout the oral cavity; the lesions may occur de novo or after pseudomembrane detachment in acute pseudomembranous candidiasis[14, 18].
Acute "erythematous" atrophic candidiasis can develop in young people with increased sensitivity to Candida fungi, as a result of the use of orthodontic structures. This form is characterized by [4,5,6, 8].
- complaints of heartburn, dryness, pain and increased sensitivity of the oral cavity to thermal and chemical stimuli;
- clinically - xerostomia, bright red hyperemia of the OM, absence of plaque. Restriction of opening the mouth, speech, eating due to dryness and pain in the OM;
- sometimes a small number of crusts are observed on the red border of the lips. When the lesion is localized on the tongue, its back has a crimson-red color, dry and bright, filiform papillae are atrophied. The plaque is absent or remains in deep folds, is removed with difficulty;
- the general condition of the patients does not suffer: there are no symptoms of intoxication, the body temperature is not changed;
- differential diagnosis is carried out with allergic drug stomatitis, desquamative glossitis, Genter-Miller glossitis, a condition accompanied by a deficiency of vitamin B12, folic acid and iron [5,6,12].
AG can be a manifestation of significant deficiencies of some essential nutrients, including riboflavin, niacin, pyridoxine, vitamin B12, folic acid, iron, etc. [9].
For AG accompanied by vitamin B12 deficiency, characteristic changes are known as Genter-Miller glossitis: painful, sharply limited stripes and spots of bright red color of an inflammatory nature appear on the tip and lateral parts of the dorsum of the tongue. Filamentous and mushroom-shaped papillae atrophy, the epithelium is thinned, the dorsum of the tongue becomes smooth, shiny, without plaque. In most cases, AG is characterized by: dryness, heartburn, numbness of the tongue and taste disturbance. The feeling of heartburn and numbness of the tongue is probably due to the loss of protection of the dorsal surface mucous membrane of the tongue of the filamentous papillae and exposure of nerve receptors. And also along with this, the loss of taste receptors, which leads to taste disturbances and reduced saliva secretion[10,11].
In addition to the history and clinical findings, blood tests are crucial in making the diagnosis. Since vitamin B12 deficiency affects the tissues of the OM, early detection of the findings may help in diagnosing the underlying cause before hematological examination is performed[7].
Desquamative glossitis (geographic tongue) is a limited violation of the processes of keratinization of the epithelium and dystrophic changes in the papillae of the tongue[4,5,6]. The disease is more common in childhood, adults, in particular in women more often than men. Desquamations on the mucose membrane of the tongue can be caused by the use of certain medications, exudative diathesis, and diseases of the gastrointestinal tract. This form of glossitis is characterized by the presence of grayish-white or red spots (desquamations) of various diameters on the dorsum and lateral surfaces of the tongue, which are limited from each other by areas of enlarged filiform papillae.
On the periphery of the lesion, a slight keratosis is observed, which causes the constant appearance of a whitish roller. Areas of desquamation have the shape of rings and semi-rings. The pattern of changes in the surface of the tongue is not constant. Several such foci of desquamation may form simultaneously, or new ones may appear on the background of old ones, merging with each other and forming various patterns, resembling a geographical map. The contours of the foci of desquamation may change their location within 1-2 days. At the site of the re-epithelialized lesion or near it, a desquamated area may form again, which is covered with epithelium after 2-3 days. In most cases, desquamative glossitis is not accompanied by subjective sensations. With a long course, a feeling of burning, itching, paresthesia in the tongue may occur. It becomes sensitive to chemical and other stimuli. The disease has a recurrent nature, remission lasts from 10 days to 3 months. Progressing, the disease acquires a permanent course - 10-15 years.
Conclusion: Candidal lesions of the OM are manifested by various clinical symptoms that can mimic serious somatic diseases, requiring more careful differential diagnosis by an oral cavity specialist. The clinical diagnosis of candidiasis of the OM should be confirmed by microscopic examination of Candida in appropriate biomaterial samples.
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