Dentistry Section DOI : 10.7860/JCDR/2016/19387.8357
Year : 2016 | Month : Aug | Volume : 10 | Issue : 08 Page : ZC109 - ZC112

Association of Oral Candida albicans with Severe Early Childhood Caries - A Pilot Study

Ann Thomas1, Sanjana Mhambrey2, Krunal Chokshi3, Achala Chokshi4, Sinjana Jana5, Sneha Thakur6, Deepak Jose7, Garima Bajpai8

1 Professor, Department of Pedodontics and Preventive Dentistry, A.J. Institute of Dental Sciences, Mangaluru, Karnataka, India.
2 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Srinivas Institute of Dental Sciences, Mangaluru, Karnataka, India.
3 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India.
4 Senior Lecturer, Depatment of Oral Pathology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India.
5 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Haldia Institute of Dental Sciences and Research, West Bengal, India.
6 Consultant Pedodontist, Nanavati Hospital, Mumbai, India.
7 Senior Lecturer, Kannur Dental College, Anjarakandy Integrated Campus, Kerala, India.
8 Consultant Pedodontist, RK’s Dental Care Centre, Korba, Chhattisgarh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Krunal Chokshi, Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India.


In early childhood, children are more susceptible to opportunistic microbial colonization in the oral cavity due to immature immune system and not fully established micro flora. The current literature proposes a probable role of Candida albicans, a fungus in the etiopathogenesis of dental caries.


This study was conducted to compare the Candida albicans count in children with severe early childhood caries and caries free children.

Materials and Methods

A cross-divtional study was conducted in 40 randomly selected healthy children between 12 to 71 months of age, who were divided into two groups based on the caries experience as Severe Early Childhood Caries (SECC) (dmfs ≥4) and caries free (dmfs = 0). The caries experiences (dmfs index) of the 40 children were recorded using visible light and diagnostic instruments. A 2ml sample of unstimulated whole saliva collected from the children was transported to the microbiology laboratory in universal containers and evaluated for Candida albicans count using the selective media. The data was statistically analyzed using SPSS software 17.0.


Candida albicans was found in both the SECC group and caries free group. Median Candida albicans of the SECC group was numerically greater than the caries free group and this difference was highly statistically significant (p=0.012).


In this present cross-divtional study, we found a 100% prevalence of Candida albicans in the saliva of the study children. There was a highly significant increase in Candida albicans count in SECC children compared to the caries free children.


Dental caries is the most common preventable oral disease known to mankind but unfortunately people are susceptible to this disease throughout their lifetime. It is the primary cause of oral pain and tooth loss. Dental caries can be arrested and is reversible in its early stages, but is often not self-limiting. Without preventive measures, proper care and clinical intervention caries can progress until the tooth is completely destroyed. The terms dental caries or caries can be used to identify both the caries process and the carious lesion (cavitated or non-cavitated) that is formed as a result of that process. Based on chronology dental caries is classified into early childhood caries, teenage caries and adult caries [1].

Early Childhood Caries (ECC) is a destructive, debilitating and the most common chronic childhood disease that affect the young children. Not life-threatening but it affects normal health and well-being of the child. Though dental caries prevalence has reduced worldwide, ECC prevalence is still high and is currently a WHO concern [2,3]. Severe ECCC as the name indicates is a severe, aggressive and debilitating form of this disease with ramifications.

Streptococcus mutans and Lactobacillus species are the main microorganisms that are implicated for the initiation and progression of dental caries respectively. In the last two decades several studies have demonstrated an association between high counts of Candida albicans, yeast with DMF scores [46]. However, a clear understanding of its role in the etiopathogenesis of dental caries is limited.

Candida an opportunistic pathogen, a normal commensal of the oral cavity is found more in younger children. M. Sonesson et al., suggested that younger children are under the state of developing immunity; and Candida species has the potential to increase in number during low immune states. This could be an important factor responsible for the rapid caries progression in children of this age group [7]. Due to compromised immunity, ECC patients are malnourished which could make them particularly prone to infection by Candida species [8].

The most prevalent Candida species in the oral cavity is Candida albicans. FG de Carvalho and Molaic E have reported a greater presence of Candida albicans in saliva, dental plaque and infected dentin of children with ECC compared to the caries free children [6,9]. However, reports of its presence in SECC are limited. Researchers have found Candida albicans to be highly acidogenic [10]; and with greater ability to dissolve hydroxyapatite crystals of enamel (approximately 20 fold) than Streptococcus mutans [10]; all these factors suggest a greater role of Candida albicans in SECC; contributing to the severity and aggressive nature of this disease. The aim of the study was to identify the association of Candida albicans with SECC, and also to assess the Candida albicans count in children of age 12-36 months and 37-71 months.

Materials and Methods

This cross-sectional study was conducted among 40 healthy children between 12-71 months of age by randomly selecting healthy children reporting to the Department of Pedodontics and Preventive Dentistry, A.J. Institute of Dental Sciences, Mangaluru, Karnataka, India. Children on antifungal or steroid therapy, with positive medical history and those for whom informed parental consent was not obtained were not included in the study. This study was conducted after the Institutional Ethical Committee reviewed and approved the study protocol.

The children included in our study were clinically examined and were divided into two groups consisting of 20 children each based on their caries experience, in accordance to the AAPD definition for SECC [11], i.e., the SECC group was the study group and the caries free group was the control group. Both groups were further divided into Subgroups A and B of 10 children each based on age, i.e., Subgroup A consisted of children between 12-36 months and Subgroup B consisted of children between 37-71 months of age.

To maintain consistency in the sample collected, we used the unstimulated, whole saliva (that pools in the floor of the mouth). It was collected by the passive drool technique and we used swabbing technique which often allows for studies with small children or other individuals that have difficulty with the passive drool technique because of their age and incompetency to cooperate. A sample of 2 ml unstimulated whole saliva was collected between 10:00am to 11:00am by both making the child to drool and also by swabbing technique. Children were made to sit in a well-lit quiet room and made to drool into sterile containers for 10 minutes. Drooled saliva sample was additionally supplemented with swabbed saliva and supragingival plaque sample, which was collected carefully by swabbing the buccal surfaces of the teeth, carious lesions and around the mucosal surface with sterile, absorbent cotton swab until saturated. Swab was then placed into a 5cc syringe and was squeezed using plunger of the syringe. Each sample was labeled and stored at -70oC and transported to the microbiology laboratory for microbiological evaluation.

The saliva samples were centrifuged at 8000rpm for one minute at room temperature. The supernatant was discarded, and 100ul normal saliva was added to the precipitate. The precipitate was then placed in Vortex mixer for 30 seconds to obtain homogenous suspensions. A 10ul of the suspension was inoculated in the chromagar medium by painting with cotton swab to spread the inoculums (Hi Media Laboratories Pvt., Ltd., Code No- M1297A, Mumbai, India) and incubated at 37oC under aerobic conditions for 48 hrs. Isolates were identified according to the different colors of colonies on the agar medium. Candida albicans appeared as green colored smooth colonies, C. glabrata appeared as purple colored smooth colonies, C. tropicalis appeared as dark blue grey colored smooth colonies, C. krusei appeared as pale pink colored smooth colonies. Candida was identified by employing API- 20C AUX and germ tube formation test.

Statistical Analysis

The data was statistically analyzed by using descriptive statistics, ‘Chi-Square’ test and ‘Mann- Whitney U’ test in SPSS software 17.0. The results were considered statistically significant at 0.05 probability levels.


The mean age of the study participants was 3.189 years and in the Subgroups A and B it was 2.08 years and 4.29 years respectively. In the SECC group, the mean ± SD of dfs index was 18.6 ± 11.67, with a minimum of 5 and the maximum of 46. All the study participants included in the SECC group had active caries, for the defs index, score here was indicative of only the d component; and there were no filled or missing teeth due to caries.

[Table/Fig-1a,b] shows the Candida albicans count in both the SECC group and caries free group. Median Candida albicans of the SECC group was numerically greater than the caries free group and this difference was highly statistically significant (p=0.012) [Table/Fig-2]. The median Candida albicans in the Subgroup B was numerically greater than Subgroup A in both SECC and caries free groups; but this difference was not statistically significant in both the groups [Table/Fig-3].

Observation for colony count of Candida albicans of all the samples.

No.SECC GroupCaries Free Group
11.6 x 1041.69 x 1058 x 1031.8 x 104
27 x 1032.5 x 1041 x 1033.4 x 104
32.17 x 1056.5 x 1041 x 1032.5 x 104
41.39 x 1053.4 x 1041 x 1032 x 103
57.7 x 1042.23 x 1051 x 1045 x 103
64.8 x 1052.96 x 1052 x 1033 x 103
71 x 1052.37 x 1051 x 1032.4 x 104
82 x 1039 x 1032.45 x 1051 x 104
92 x 1037 x 1036 x 1031 x 104
103.3 x 1041 x 1031.67 x 1051 x 103

Chromagar for the detection of Candida albicans in SECC and caries free sample (respectively).

Candida albicans count in SECC and caries free groups.

SECC203.35 x 1041.975 x 1051x 1034.8 x 10525.15-2.5230.012**
Caries Free207 x 1032.125 x 1041 x 1032.45x 10515.85

**- Highly significant

IQR - Inter-quartile range

Z - Z-test

p - Probability

Tests done - Median, Minimum, Maximum Mean Rank, Probability.

Candida albicans count in the subgroups of both the SECC and caries free groups.

GroupSub- GroupNMedianCFU/mlIQRMinMaxMeanRankZp-value
SECCA102.45 x 1041.5 x 1052.0 x 1034.8 x 1059.75-0.5670.570NS
B104.95 x 1042.2 x 1051.0 x 1032.96 x 10511.25
Caries FreeA104.0 x 1044.8 x 1041.0 x 1032.45 x 1059.15-1.0300.303NS
B101.0 x 1042.15 x 1041.0 x 1033.4 x 10411.85

NS- Not significant

Z - Z-test

p - Probability

IQR- Inter-quartile range

Tests done - Median, Minimum, Maximum Mean Rank, Probability

Comparison of the median Candida albicans count between the study subgroup and the control subgroup (i.e., SECC Subgroup A and caries free Subgroup A and between SECC Subgroup B and caries free Subgroup B) within the subgroups based on age revealed that Candida albicans count was numerically higher in the study subgroup compared to the control; but this difference was statistically significant only between the Subgroup B (p=0.045).


Early childhood caries is an infectious disease of bacterial origin. The disease is the result of frequent sugar intake leading to changes in the oral microbial ecology to a cariogenic microflora, leading to an imbalance between the demineralization and remineralization process, favoring demineralization of the teeth. Thus, acidity is a pre-requisite for caries formation, and acidogenic microflora plays an important role [12].

SECC is a destructive form of dental caries affecting very young children. A number of studies have been reported regarding its prevalence, etiopathogenesis, prevention and management; but still the prevention and management of this disease remains a challenge to the dental practitioner [13]. Streptococcus mutans and Lactobacillus species are the main microorganism responsible for the initiation and progression of caries respectively. Actinomyces, Bacteroids, Bifdobacterium, Campylobacter, Capnocytophaga, Cornybacteria, Fusobacteria, Neisseria, Prevotella, Selenomonas, Veillonella species, Propionibacterium, Atopobium and other low pH non-streptococci are the other microorganisms implicated in caries pathogenesis. Currently researchers have questioned the role of Candida in ECC [14].

There is an ability of Candida albicans and Streptococcus mutans together to form biofilm which is enhanced in vitro and in vivo. The Candida albicans helps in the production of Exopolysaccharides (EPS), such that co-species biofilms will receive more biomass and harbor more viable Streptococcus mutans cells in increasing increments than single-species biofilms. The three dimensional biofilm architecture which is formed as a result of that displays sizeable Streptococcus mutans microcolonies surrounded by fungal cells, which are enmeshed in a dense EPS-rich matrix. The samples which were simultaneously infected by both species showed higher levels of infection and microbial carriage within plaque biofilms than those infected with either species alone. Furthermore, simultaneously infected EPS-rich matrix synergistically enhanced biofilm virulence, leading to aggressive onset of the rampant carious disease lesions [15]. Studies revealed that glucosyltransferase-derived EPS is a key mediator of co-species biofilm development and that coexistence with Candida albicans causes the virulence genes in Streptococcus mutans (e.g., gtfB, fabM) to express itself. Studies have shown that fungal mannan and β-glucan provide sites for gtfB binding and gtfB activity. Candida-derived β1, 3-glucans contribute to the EPS matrix structure. The severity of a ubiquitous infectious disease in a clinically relevant site occurs by a novel mutualistic bacterium-fungus relationship [15].

Candida species are fungi which are common inhabitants of the normal oral microbiota found in infants. Candida is an opportunistic pathogen and in immunocompromised individuals it has the ability to cause a variety of infections. For instance till date, oral thrush in infants and chronic atrophic candidiasis (denture induced stomatitis) in adult are the known most common clinical manifestations of oral candidiasis. Candida albicans is the most prevalent Candida species in the oral cavity. Studies suggest the presence of Candida albicans in saliva, dental plaque and also infected dentin of children with early childhood caries [9,10].

M. Sonesson et al., suggested that children of age below four years are under the state of developing immunity; and Candida spp. has potential to increase in number during low immune states. This could be an important factor for the rapid caries progression in children of this age group [7]. Candida albicans can exist in three morphotypes namely budding yeast, pseudohypha, and true hypha and hence, is called a polymorphic fungus. The morphological change from yeast to hyphal cells is important for its virulence and biofilm formation. Studies have found the isolation of yeast to be in proportion with increase in number of carious teeth, and reported an association between dental caries and the presence of yeast in the oral cavity.

Candida albicans is considered a normal commensal of the oral cavity, yet studies have reported Candida carriage to range from 23.7% - 89% in ECC and 7%-21% in caries free children [5,1618]. Higher prevalence of Candida was also found in children using pacifiers. Its presence in the oral cavity may be related to many factors such as baby’s feeding bottles, infected pacifiers, infection at birth, nurse fingers, hospital maternity ward, maternal skin, air, water and carious teeth. However, our study showed 100% Candida prevalence from saliva of caries and caries free children [Table/Fig-1]. Our finding is also contradictory to that of Thaweboon et al., who reported an absence of Candida in caries free group [19,20].

Candida albicans count was found to be significantly higher in SECC group as compared to the caries free group [Table/Fig-2]. This finding is similar to that of many studies which have found the isolation of yeast to be in proportion with increase in number of carious teeth, and suggested a possible association between presence of yeast in the oral cavity and dental caries [3,6,2123], but was in contradiction to Fabiola Galbiatti de Carvalhoa who found Candida levels in caries free group to be higher when compared to the SECC group [24]. The severity of the disease in SECC could be attributed to the greater role played by Candida albicans with its greater acidogenic potential. Role of Candida albicans in SECC needs further exploration for better understanding the etiopathogenesis of SECC.

Another assumption in this study was that since children below three years of age are under the state of developing immunity, they are at a higher risk for opportunistic infection namely Candida. Considering the acidogenic potential of Candida it could be the probable reason for the severity of the disease progression during early childhood. However, our finding was contradictory to the above assumption, i.e., Candida albicans count was lower in 12-36 months old children in both the SECC group and caries free group than 37-71 months old children and also absence of a significant difference in colony counts between the SECC Subgroup and caries free Subgroup in the 12-36 months old children (Group A).


This article emphasizes on Candida albicans association with the caries process. The study has some limitations. The sample size was small so we cannot extrapolate these data to all individuals and all situations. It still remains unclear whether Candida species are causative agents in early childhood caries initiation or progression, or whether Candida colonization is merely a consequence of severe early childhood caries activity. Further research is required to elucidate the real role of this microorganism in the etiology of dental caries, which may help in management and prevention of this disease.


A high association was found between Candida albicans and SECC in this study. This study suggests that Candida albicans may be responsible for initiation and progression of SECC in the very young children with immature immune system.

Mouth rinses are used generally for their analgesic, anti-inflammatory, antimicrobial and anticariogenic activities to decrease the prevalence of dental caries in addition to the usual prophylactic measures like brushing and flossing. In addition to this anti-fungal agents should also be used so that the growth of Candida albicans (a fungus) is under control to prevent any dental caries caused due to it. Further studies are required in this area to help in management and prevention of this chronic childhood disease.

**- Highly significantIQR - Inter-quartile rangeZ - Z-testp - ProbabilityTests done - Median, Minimum, Maximum Mean Rank, Probability.NS- Not significantZ - Z-testp - ProbabilityIQR- Inter-quartile rangeTests done - Median, Minimum, Maximum Mean Rank, Probability


[1]Selwitz RH, Ismail AI, Pitts NB, Dental caries Lancet 2007 369(9555):51-59.  [Google Scholar]

[2]Poul EP. Continuous Improvement of Oral Health in the 21stCentury – The Approach of the WHO Global Oral Health Programme; World Oral Health Report, 2003 WHO/NMH/NPH/ORH/03.2  [Google Scholar]

[3]Low W, Tan S, Schwart S, The effect of severe caries on quality of life in young children Pediatric Dent 1999 21:325-26.  [Google Scholar]

[4]Signoretto C, Burlacchini G, Faccioni F, Zanderigo M, Bozzola N, Canepari P, Support for the role of candida spp in extensive caries lesion of children New Microbiol 2009 32(1):101-07.  [Google Scholar]

[5]Gábris K, Nagy G, Madléna M, Dénes Z, Márton Keszthelyi G, Associations between microbiological and salivary caries activity tests and caries experience in hungarian adolescents Caries Res 1999 33(3):191-95.  [Google Scholar]

[6]De Carvalho FG, Parisotto TM, Presence of Candida spp. in infants oral cavity and its association with early childhood caries Brazilian J Oral Sci 2007 6:1249-53.  [Google Scholar]

[7]Sonesson M, Eliasson L, Matsson L, Minor salivary gland secretion in children and adults Arch Oral Biol 2003 48:535-39.  [Google Scholar]

[8]Gregoire S, Xiao J, Silva BB, Gonzalez I, Agidi PS, Klein MI, Role of Glucosyltransferase B in interaction of Candida albicans with Streptococcus mutans and with an experimental pellicle on hydroxyapatite surfaces Appl Environ Microbiol 2011 77(18):6357-67.  [Google Scholar]

[9]Moalic E, Gestalin A, Quinio D, Gest PE, Zerilli A, Le Flohic AM, The extent of oral fungal flora in 353 students and possible relationship with dental caries Caries Res 2001 35:149-55.  [Google Scholar]

[10]Wetzel WE, Hanisch S, Sziegoleit A, The germ colonization of the oral cavity in small children with the nursing bottle syndrome Schweiz Monatsschr Zahnmed 1993 103:1107-12.  [Google Scholar]

[11]Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH, Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Reis and Services Administration, and the Health Care Financing Administration J Public Health Dent 1999 59(3):192-97.  [Google Scholar]

[12]Jose T, Thomas A, Candida a probable etiology in early childhood caries- a literature review J Odontol Res 2015 3(1):15-22.  [Google Scholar]

[13]Çolak H, Çoruh TD, Dalli M, Hamidi MM, Early childhood caries update: A review of causes, diagnoses, and treatments J Nat Sci Biol Med 2013 4(1):29-38.  [Google Scholar]

[14]Scott NP, Snesrud E, Liu J, Ana CO, Kilian M, Schork NJ, The dental plaque microbiome in health and disease PLoS One 2013 8(3):1-10.  [Google Scholar]

[15]Megan LF, Marlise IK, Punsiri MC, Scott-Anne K, Gregoire S, Chia-Hua P, Symbiotic relationship between streptococcus mutans and candida albicans synergizes virulence of plaque biofilms in vivo. Infect Immun 2014 82(5):1968-81.  [Google Scholar]

[16]Peretz B, Mazor Y, Candida, mutans streptococci, oral hygiene and caries in children J Clin Pediatr Dent. Winter 2011 36(2):185-88.  [Google Scholar]

[17]Hossain H, Ansari F, Schulz-Weidner N, Clonal identity of Candida albicans in the oral cavity and the gastrointestinal tract of pre-school children Oral Microbiol Immunol 2003 18(5):302-08.  [Google Scholar]

[18]Marchant S, Brailsford SR, Twomey AC, Roberts GJ, Beighton D, The predominant microflora of nursing caries lesions Caries Res 2001 35(6):397-406.  [Google Scholar]

[19]doRego MA, Koga-Ito CY, Jorge AO, Effects of oral environment stabilization procedures on counts of Candida spp. in children Pesqui Odontol Bras 2003 17(4):332-36.  [Google Scholar]

[20]Thaweboon S, Thaweboon b, Nakornchai S, Jitmaitree S, Salivary secretory IgA, pH, flow rates, mutans streptococci and Candida in children with rampant caries Southeast Asian J Trop Med Public Health 2008 39:893-99.  [Google Scholar]

[21]Beighton D, Adamson A, Rugg-Gunn A, Associations between dietary intake, dental caries experience and salivary bacterial levels in 12-year-old english school children Arch Oral Biol 1996 41(3):271-80.  [Google Scholar]

[22]Cerqueira DF, Portela MB, Pomarico L, Soares RM, de Souza IP, Castro GF, Examining dentinal carious lesions as a predisposing factor for the oral prevalence of Candida spp. in HIV- infected children J Dent Child 2007 74(2):98-103.  [Google Scholar]

[23]Thein ZM, Samaranayake YH, Samaranayake LP, Effect of oral bacteria on growth and survival of Candida albicans biofilms Arch Oral Biol 2006 51(8):672-80.  [Google Scholar]

[24]Nikawa H, Yamashiro H, Makihira S, In vitro cariogenic potential of Candida albicans Mycoses 2003 46:471-78.  [Google Scholar]