White Lesions on Gums in a 6-Year-Old Child
The most likely diagnosis is oral candidiasis (thrush), which should be treated with topical antifungal therapy such as nystatin suspension or miconazole gel, while also considering other common differential diagnoses including dental plaque biofilm, traumatic ulcers, and viral stomatitis. 1
Differential Diagnosis
The white plaques on gums in a 6-year-old require systematic evaluation of several key possibilities:
Primary Considerations
Oral candidiasis (thrush): Presents as thick, yellowish-white patches on oral mucosa that can involve the gums 2, 3. However, it's important to note that clinical diagnosis based solely on white patches may be misleading—one study found that C. albicans was not discovered in babies with clinical thrush, and the etiology of white patches remained unclear in many cases 2.
Dental plaque biofilm: In 6-year-old children, dental plaque formation is common and appears as white-to-yellowish deposits on gum surfaces 4. Plaque biofilm in children contains both supragingival and subgingival bacteria, with the host response causing gingival inflammation and enlargement (gingivitis) 4.
Traumatic ulcers with white coating: These typically heal within 7-10 days once the source of trauma is identified and removed 1.
Viral stomatitis: May present with white lesions but typically includes other features like vesicles or ulcerations 1.
Key Distinguishing Features
For candidiasis, look for:
- Thick, yellowish-white patches that may be removable 2, 3
- Associated burning sensation 3
- Predisposing factors: recent antibiotic use, immunosuppression, diabetes, poor oral hygiene, or corticosteroid use 5, 6
- Maternal mastitis history (in younger children) 2
For dental plaque, look for:
- White-to-yellowish deposits along the gum line 4
- Gingival inflammation and redness 4
- Poor oral hygiene history 4
- Removable with mechanical cleaning 4
Management Algorithm
Step 1: Initial Assessment and Risk Stratification
Evaluate for predisposing factors:
- Recent antibiotic or corticosteroid use 5, 6
- Immunocompromised state 5, 6
- Diabetes 6
- Poor oral hygiene practices 4, 7
Step 2: Treatment Based on Most Likely Diagnosis
If oral candidiasis is suspected:
- Initiate topical antifungal therapy with nystatin suspension or miconazole gel 1, 5
- Topical antimycotic treatment is important to prevent spread of infection 5
- For immunocompromised patients with chronic infections, long-term antifungal therapy may be required 5
- Avoid acidic liquids (lingonberry juice, lemon juice) as treatment—these are not efficient and lack evidence 2
If dental plaque/gingivitis is suspected:
- Institute twice-daily brushing with pea-sized amount (0.25g) of fluoride toothpaste (1,000-1,100 ppm) 1, 8
- Provide gentle mechanical plaque removal 1, 7
- Establish dental home if not already done (recommended by 12 months of age) 1
- Apply fluoride varnish every 3-6 months 1, 8
If traumatic ulcer is suspected:
- Identify and remove source of trauma 1
- Provide supportive care with acetaminophen or ibuprofen for pain 1
- Offer cold fluids and soft foods 1
- Expect healing within 7-10 days 1
If viral stomatitis is suspected:
- Supportive care only—no antiviral therapy indicated for immunocompetent children 1
- Pain management with acetaminophen or ibuprofen 1
- Maintain hydration with cold, non-acidic fluids 1
Step 3: Supportive Care for All Etiologies
- Pain management: Acetaminophen or ibuprofen 1
- Coating agents: Milk of magnesia may provide temporary relief 1
- Dietary modifications: Cold fluids and soft, bland foods 1
- Maintain oral hygiene: Continue gentle brushing twice daily 1
Step 4: Follow-Up and Reassessment
- If lesions persist beyond 2 weeks despite appropriate treatment, reconsider diagnosis 2
- For candidiasis, recurrences are frequent if predisposing conditions are not corrected 5
- Ensure compliance with oral hygiene measures 7
Critical Pitfalls to Avoid
- Do not prescribe antibiotics empirically—most oral lesions in children are viral and self-limited 1
- Do not rely solely on clinical appearance for candidiasis diagnosis—white patches may have unclear etiology even when they appear classic for thrush 2
- Do not use acidic liquids (lingonberry or lemon juice) to treat suspected thrush—this approach is not efficient 2
- Do not overlook poor oral hygiene as both a cause and perpetuating factor for multiple oral conditions 4, 7
- Do not forget to address predisposing factors—treating the infection alone without correcting underlying conditions leads to recurrence 5